Anthem BlueCross BlueShield

Anthem Bronze Pathway/Lean HSA (+ Incentives)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,250.00 Family: $16500 Per Person: $8250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,250.00 Family: $16500 Per Person: $8250

Office Visit

Primary Doctor

CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) ? Limited to a maximum of 60 days per Member, per Calendar Year.
Inpatient Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Excludes services related to surrogacy if member is not the surrogate.
Pre and Postnatal Office Visit	CoPay: No Charge after deductible CoInsurance: Not Applicable 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	Covered: Not Covered