Anthem BlueCross BlueShield

Anthem Silver X HMO 4500

Plan Overview

Medical Deductible
  • Individual: $4,500
  • Family: $9,000
  • Per Person: $4,500
Prescription Drug Deductible
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical
Medical Out-of-Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700
Drug Out-of-Pocket Maximum
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical

Office Visit

Primary Doctor
  • Standard: $45 Copay
Specialist
  • Standard: $80 Copay

Prescription Drug Information

Preferred Brand Drugs
  • Standard: $40 Copay
Non Preferred Brand Drugs
  • Standard: 40% Coinsurance after deductible
Generic Drugs
  • Standard: $10 Copay
Specialty Drugs
  • Standard: 40% Coinsurance after deductible

Inpatient Coverage

Hospital Services
  • Standard: $1000 Copay per stay with deductible<br>40% Coinsurance after deductible
Inpatient Services
  • Standard: 40% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room
  • Standard: $500 Copay with deductible<br>40% Coinsurance after deductible
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