Anthem BlueCross BlueShield

Anthem Silver Mountain Enhanced X 3300 for HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $3,300 Family: $6,600 Per Person: $3,300
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Specialist	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 25.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 20.00% Coinsurance after deductible