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
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 |