Anthem Health - Anthem Silver Convenient Care X 100 ($0 Preferred Virtual PCP $0 Select Drugs + Incentives) S06
Primary Care Visit
$0 Copay
100% Coinsurance
Specialist Visit
$25 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$0 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$25 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
10% Coinsurance after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$100 Copay after deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
100% Coinsurance
Generic Drugs
$5 Copay
100% Coinsurance
Preferred Brand Drugs
$15 Copay
100% Coinsurance
Non-Preferred Brand Drugs
10% Coinsurance after deductible
100% Coinsurance
Specialty drugs
20% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
10% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
10% Coinsurance after deductible
100% Coinsurance
Emergency Room Services
$150 Copay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
$150 Copay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
Emergency Transportation/Ambulance
10% Coinsurance after deductible
10% Coinsurance after deductible
Urgent Care
$50 Copay
$50 Copay
Inpatient Hospital Services
$50 Copay per stay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
10% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
10% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$50 Copay per stay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
10% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$50 Copay per stay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
100% Coinsurance
Prenatal and postnatal care
10% Coinsurance after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$50 Copay with deductible
10% Coinsurance after deductible
10% Coinsurance after deductible
100% Coinsurance
Home Healthcare Services
10% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
10% Coinsurance after deductible
100% Coinsurance
Habilitation Services
10% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
10% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
10% Coinsurance after deductible
100% Coinsurance
Hospice Services
10% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
10% Coinsurance after deductible
100% Coinsurance
Acupuncture
Not Covered
Not Covered
Rehabilitative Speech Therapy
10% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
10% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
10% Coinsurance after deductible
100% Coinsurance
Diabetes Education
10% Coinsurance after deductible
100% Coinsurance
Nutritional Counseling
10% Coinsurance after deductible
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
$25 Copay
100% Coinsurance
Basic Dental Care (Adult)
Not Covered
Not Covered
Basic Dental Care (Child)
Not Covered
Not Covered
Dental Check Up (Child)
Not Covered
Not Covered
Major Dental Care (Adult)
Not Covered
Not Covered
Major Dental Care (Child)
Not Covered
Not Covered
Orthodontia (Adult)
Not Covered
Not Covered
Orthodontia (Child)
Not Covered
Not Covered
Routine Dental Services (Adult)
Not Covered
Not Covered