Silver PPO Standard Pathway – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $60 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $5,000 per person $5,000 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $450 copay after deductible |
| Ambulance | No charge |
| Hospital stay (facility) | first 4 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 | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 4 day(s) $500 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $45 per script after deductible copay |
| Non-preferred Brand | $70 per script after deductible copay |
| Specialty | 20% after deductible, up to $200 per script copay, 20% after deductible, up to $200 per script |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | first 5 visit(s) $75 then $0 copay |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | first 4 day(s) $500 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/fi8DV97reaZcZsF4Zv4jXxdZ.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
