Anthem BlueCross BlueShield

Anthem Silver Priority/Lean Standard ($0 Virtual PCP + $0 Select Drugs + Incentives)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,000.00 Family: $10000 Per Person: $5000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Office Visit

Primary Doctor

CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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: $80.00
CoInsurance: Not Applicable
Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail
Non Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail
Specialty Drugs	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply retail

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) ? Limited to a maximum of 60 days per Member, per Calendar Year.
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Excludes services related to surrogacy if member is not the surrogate.
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 : Visit(s) per Year

Major Dental Care

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