Anthem BlueCross BlueShield

Anthem Silver X 3300 Adult Dental/Vision ($0 Preferred Virtual PCP $0 Select Drugs + Incentives)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $3,300 Family: $6600 Per Person: $3300
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000 Family: $16000 Per Person: $8000

Office Visit

Primary Doctor	CoPay: $10.00 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.
Specialist	CoPay: $50.00 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.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Copayment is waived if admitted
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered
Basic Dental Care - Adult	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Major Dental Care - Child	Covered: Not Covered