Gold PPO Standard Pathway – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,300 per person $1,300 per person |
| Out-of-pocket max | $7,375 per person $14,750 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $400 copay |
| Ambulance | No charge |
| Hospital stay (facility) | first 2 day(s) $500 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $500 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 2 day(s) $500 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $35 per script copay |
| Non-preferred Brand | $60 per script copay |
| Specialty | 20% after deductible, up to $100 per script copay, 20% after deductible, up to $100 per script |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | $65, up to $375 copay |
| Blood work | $10 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | first 2 day(s) $500 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/cf8QvaGqE8Uw6Z1mbnfe8vU9.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
