Anthem BlueCross BlueShield

Anthem Silver Mountain Enhanced X HMO 6500 Rx Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $6,500 Family: $13,000 Per Person: $6,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000 Family: $16,000 Per Person: $8,000

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Non Preferred Brand Drugs	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Specialty Drugs	CoPay: $650.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.

Inpatient Coverage

Hospital Services	CoPay: $1000.00 Copay per Stay with deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay with deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $1000.00 Copay with deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per year

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

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