Anthem BlueCross BlueShield

Silver PPO Standard Pathway

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $4,300 Family: $8,600 Per Person: $4,300
Prescription Drug Deductible	Individual: $250 Family: $500 Per Person: $250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,600 Family: $17,200 Per Person: $8,600

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable 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.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable 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.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $45.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Non Preferred Brand Drugs	CoPay: $70.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Maximum of 4 daily copays per in network admission. Copay applies after deductible has been met.
Inpatient Services	CoPay: $0.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $450.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Emergency Room copay is waived if directly admitted to the hospital.
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Maximum of 4 daily copays per in network admission. Copay applies after deductible has been met.
Pre and Postnatal Office Visit	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Limited reimbursement for out of network. You will be responsible for any costs over this limited reimbursement amount.

Major Dental Care

Routine Dental Checkups for Children	CoPay: $0.00 CoInsurance: Not Applicable 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: 40.00% Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

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