Anthem Silver X 6500 Medicaid Transition Plan ($0 Preferred Virtual PCP $0 Select Drugs)
Anthem BlueCross BlueShield
Plan overview
Medical deductible
Individual: $6500
Family: $13000
Per Person: $6500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8000
Family: $16000
Per Person: $8000
Office visit
Primary Doctor
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: You may 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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: You may 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: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply
Generic drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply. $0 Select Drugs: We offer a $0 cost share for a select set of tier 1 (Generic) prescription drugs. Certain low-cost drugs, on Tier 1, may be available to Members at no Cost Share. These drugs are listed on Our Prescription Drug List (formulary).
Specialty drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply
Inpatient coverage
Hospital services
CoPay: $1000.00 Copay per Stay with deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $500.00 Copay with deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: When directly admitted to the hospital, the Emergency Room Copay is NOT waived.
Urgent care facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $1000.00 Copay with deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 40.00% 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
Benefit Explanation: Eye exams are covered once per benefit period.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).