Gold HMO Pathway Enhanced with Added Dental and Vision Benefits – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $50 copay
Specialist visit: $80 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | 10% after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $50 per script copay |
| Non-preferred Brand | 20%, up to $500 per script copay, 20%, up to $500 per script coinsurance |
| Specialty | 20%, up to $1,000 per script copay, 20%, up to $1,000 per script coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 10% after deductible |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/miu93WkjGZDMJD8CaVR2BWY3.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
