Bronze PPO Standard Pathway HSA
Anthem BlueCross BlueShield
Links:
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: $7225
Family: $14450
Per Person: $7225
Office visit
Primary Doctor
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: You may able to access care with using our online virtual doctor visits and medical chat with a doctor.
Specialist
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Generic drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply for Retail or 30 day supply for Home Delivery. Retail Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Inpatient coverage
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 and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation:
Maternity
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: 0.00%
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Benefit Explanation: Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam. Limited reimbursement for out of network. You will be responsible for any costs over this limited reimbursement amount.
Major dental care
Routine dental checkups for children
CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 2
Limit Unit: Visit(s) per Year
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not 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).