Anthem Silver Pathway X Transition HMO 4500 Adult Dental & Vision ($0 Virtual PCP + $0 Select Rx) – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $75 copay
Urgent care visit: $50 copay

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Description

Health Care Plan Details

Network type HMO
Deductible $4,500 per person $4,500 per person
Out-of-pocket max $9,200 per person $18,400 per family
Metal tier Silver

Visit Copay

Primary care visit $30 copay
Specialist visit $75 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 20% coinsurance after deductible
Ambulance 20% coinsurance after deductible
Hospital stay (facility) 20% coinsurance after deductible
Hospital stay (physician) 20% coinsurance after deductible
Outpatient procedure (facility) 20% coinsurance after deductible
Outpatient procedure (physician) 20% coinsurance after deductible
Physical rehabilitation $30 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $75 copay
Non-preferred Brand 40% coinsurance after deductible
Specialty 40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 20% coinsurance after deductible
Imaging (CT/PET/MRI) No charge after deductible
Blood work 20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 20% coinsurance after deductible
Psychiatric hospital stay 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/Qd5PQPUgPEphBfTSqMmJPd5X.pdf