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Anthem Health   -   Anthem Silver Convenient Care X 5500 ($0 Preferred Virtual PCP $0 Select Drugs + Incentives)

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
$5 Copay
100% Coinsurance
Specialist Visit
$60 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$5 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
30% Coinsurance after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
$50 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
30% Coinsurance after deductible
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$10 Copay
100% Coinsurance
Preferred Brand Drugs
$40 Copay
100% Coinsurance
Non-Preferred Brand Drugs
40% Coinsurance after deductible
100% Coinsurance
Specialty drugs
50% Coinsurance after deductible
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
30% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
30% Coinsurance after deductible
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
$650 Copay after deductible
50% Coinsurance after deductible
$650 Copay after deductible
50% Coinsurance after deductible
Emergency Transportation/Ambulance
30% Coinsurance after deductible
30% Coinsurance after deductible
Urgent Care
$50 Copay
$50 Copay
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
$1000 Copay per stay with deductible
30% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
30% Coinsurance after deductible
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
30% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$1000 Copay per stay with deductible
30% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
30% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$1000 Copay per stay with deductible
30% Coinsurance after deductible
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
30% Coinsurance after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$1000 Copay with deductible
30% Coinsurance after deductible
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
30% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
30% Coinsurance after deductible
100% Coinsurance
Habilitation Services
30% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
30% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
30% Coinsurance after deductible
100% Coinsurance
Hospice Services
30% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
30% Coinsurance after deductible
100% Coinsurance
Acupuncture
Not Covered
Not Covered
Rehabilitative Speech Therapy
30% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
30% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
30% Coinsurance after deductible
100% Coinsurance
Diabetes Education
$60 Copay
100% Coinsurance
Nutritional Counseling
30% Coinsurance after deductible
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
$60 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

Carrier Notices

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