Anthem Silver Pathway X Transition HMO 4200 for HSA ( + Incentives) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,200 per person $4,200 per person
Out-of-pocket max	$5,950 per person $11,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	15% coinsurance after deductible
Specialist visit	15% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	15% coinsurance after deductible
Emergency room	$300 copay after deductible, 15% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	15% coinsurance after deductible
Outpatient procedure (facility)	15% coinsurance after deductible
Outpatient procedure (physician)	15% coinsurance after deductible
Physical rehabilitation	15% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay after deductible, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay after deductible
Brand	$40 copay after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	15% coinsurance after deductible
Imaging (CT/PET/MRI)	$300 copay after deductible, 50% coinsurance after deductible
Blood work	15% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	15% coinsurance after deductible
Psychiatric hospital stay	$500 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits

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