Anthem BlueCross BlueShield

Anthem Bronze Pathway X 9200 $0 Select Drugs

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $9,200 Family: $18,400 Per Person: $9,200
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $50.00 \| Coinsurance: No Charge after deductible
Specialist	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 0.00% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 0.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: Not Applicable \| Coinsurance: 0.00% Coinsurance after deductible
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 0.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable
Inpatient Services	Standard: Copay: No Charge after deductible \| Coinsurance: Not Applicable

Emergency and Urgent Care

Emergency Room

Standard: Copay: No Charge after deductible | Coinsurance: Not Applicable