Anthem Bronze Mountain Enhanced X 6000 $0 Select Drugs
Anthem BlueCross BlueShield
Links:
Plan overview
Medical deductible
Individual: $6000
Family: $12000
Per Person: $6000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $10600
Family: $21200
Per Person: $10600
Office visit
Primary Doctor
CoPay: $50.00
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copay applies for first 3 visits, then ded/coins
Specialist
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Generic drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share reflects a 30 day retail supply. $0 Select Drugs: We offer a $0 cost share for a select set of tier 1 (Generic) prescription drugs. Certain low-cost drugs, on Tier 1, may be available to Members at no Cost Share. These drugs are listed on Our Prescription Drug List (formulary).
Specialty drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 30.00% 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: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 2
Limit Unit: Visit(s) per Year
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).