Anthem BlueCross BlueShield of Georgia

Anthem Bronze Pathway X Guided Access 7500/50%

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Network

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,500.00 Family: $15000.0 Per Person: $7500.0
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400.0 Per Person: $9200.0

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.
Specialist	CoPay: $100.00 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 mobile app or website.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 90 day retail supply. The copay or coinsurance shown is for services provided in Level 1 Pharmacy. If you choose a Level 2 Pharmacy, you will have a higher copay or coinsurance.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 90 day retail supply. The copay or coinsurance shown is for services provided in Level 1 Pharmacy. If you choose a Level 2 Pharmacy, you will have a higher copay or coinsurance.
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 90 day retail supply. The copay or coinsurance shown is for services provided in Level 1 Pharmacy. If you choose a Level 2 Pharmacy, you will have a higher copay or coinsurance.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 90 day retail supply. The copay or coinsurance shown is for services provided in Level 1 Pharmacy. If you choose a Level 2 Pharmacy, you will have a higher copay or coinsurance.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services.
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room

CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copayment (if applicable) is waived if admitted.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

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

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered