Anthem BlueCross BlueShield

Anthem Heart Healthy Bronze Pathway/Lean 0 Med Ded ($0 Virtual PCP+$0 Select Drugs+Incentives)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $2,900.00 Family: $5800 Per Person: $2900
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor

CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cardiologist office visits will follow this cost share. Office Visits apply to deductible/coinsurance. You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.

Specialist

CoPay: $200.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cardiologist office visits will follow the Primary Care Visit to Treat and Injury or Illness cost share. Office Visits apply to deductible/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: $175.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 45.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail

Inpatient Coverage

Hospital Services	CoPay: $3200.00 Copay per Stay 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: Not Applicable CoInsurance: 50.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $3,000.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $3,200.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Excludes services related to surrogacy if member is not the surrogate.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% 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