Anthem BlueCross BlueShield

Anthem Bronze Pathway X Enhanced HMO 4500 15

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Combined Medical and Drug Deductible	Individual: $4,500 Family: $9,000 Per Person: $4,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Primary Doctor

CoPay: $20.00 Copay with deductible
CoInsurance: 15.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copay applies for the first 3 visits for Primary care, Retail Health Clinic and Chiropractic office visits combined. Additional office visits are subject to the deductible. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Specialist

CoPay: $50.00 Copay after deductible
CoInsurance: 15.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Generic Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share is for a 30 day supply.

Hospital Services	CoPay: $500.00 Copay per Stay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 15.00% Coinsurance after deductible Covered: Covered

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered Benefit Explanation: If applicable, copay waived if admitted.
Urgent Care Facility	CoPay: $50.00 Copay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: 15.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: This Plan covers a complete eye exam and if needed, dilation.

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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