Anthem BlueCross BlueShield

Anthem Silver Pathway X Transition HMO 4000 Adult Dental/Vision ($0 Virtual PCP + $0 Select Rx)

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Combined Medical and Drug Deductible	Individual: $4,000 Family: $8000 Per Person: $4000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,200 Family: $16400 Per Person: $8200

Primary Doctor	CoPay: $30.00 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.
Specialist	CoPay: $75.00 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: $75.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply.
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% 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: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency Room

Urgent Care Facility

CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Urgent care visits are covered in full for first 3 visits. Urgent care Visits 4+ are subject to $50 copay. Copay is for Urgent care visit only, 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.

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Routine Eye Exams for Children

CoPay: No Charge
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	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Adult routine Dental Services includes oral evaluations and cleanings covered two times per 12-month period, one series of bitewing x-rays per 12-month period, and full mouth or panoramic x-rays covered one time per 60-month period
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered