Anthem BlueCross BlueShield

Anthem Bronze Pathway X HMO 9200 ($0 Virtual PCP + $0 Select Drugs)

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Combined Medical and Drug Deductible	Individual: $9,200.00 Family: $18400 Per Person: $9200
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Primary Doctor	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cardiologist office visits will follow this cost share. 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: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cardiologist office visits will follow the Primary Care Visit to Treat and Injury or Illness cost share. 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.

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply. $0 Select Drugs: We offer a $0 cost share for a select set of tier 1 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: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply

Hospital Services

CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) is limited to a maximum of 60 days per member, per calendar year. Coverage includes inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is medically necessary.

Inpatient Services

Emergency Room	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Copay waived if admitted.
Urgent Care Facility	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Urgent Care center services received outside of the service area are not covered, unless the service is rendered at a BlueCard facility. If out of area Urgent Care services are rendered at a BlueCard facility, the cost share is the same as In Network.

Labor and Delivery Hospital Stay

CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Coverage includes inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. Covered services include at-home post delivery care visits at your residence by a Physician or Nurse performed no later than 72 hours following you and your newborn child?s discharge from the hospital.

Pre and Postnatal Office Visit

CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Services related to surrogacy are excluded if the member is not the surrogate.

Routine Eye Exams for Children

Routine Dental Checkups for Children	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	Covered: Not Covered