Anthem BlueCross BlueShield

Anthem Bronze Pathway X HMO 7050 for HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,050 Family: $14,100 Per Person: $7,050
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,050 Family: $14,100 Per Person: $7,050

Office Visit

Primary Doctor	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share shown is for a 30-day supply.

Inpatient Coverage

Hospital Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
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
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
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

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