Anthem BlueCross BlueShield

Anthem Catastrophic Pathway Transition X HMO 9200 (+ Incentives)

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Combined Medical and Drug Deductible	Individual: $9,200 Family: $18400 Per Person: $9200
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200 Family: $18400 Per Person: $9200

Primary Doctor

CoPay: $40.00
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: First 3 combined visits to the office of a PCP or Other Practitioner (Nurse, Physician Assistant) are subject to copay. Visits 4+ subject to deductible and coinsurance. Other services provided during the visit may be subject to additional cost shares. 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 or website.

Specialist

CoPay: No Charge after deductible
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. These can be accessed via our Sydney application or website. Other services provided during the visit may be subject to additional cost shares.

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. Certain Specialty drugs are covered only when purchased from the specialty preferred provider and are not available at a Retail Pharmacy or through the Home Delivery (Mail Order) Pharmacy.

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

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

Routine Eye Exams for Children

CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: Limited to 2 visits per benefit 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