Anthem Health - Anthem Silver Pathway X Guided Access HMO 200 S06
Primary Care Visit
$5 Copay
100% Coinsurance
Specialist Visit
$75 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$5 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
40% Coinsurance after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
40% Coinsurance after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
40% Coinsurance after deductible
100% Coinsurance
Generic Drugs
$10 Copay
100% Coinsurance
Preferred Brand Drugs
$20 Copay
100% Coinsurance
Non-Preferred Brand Drugs
40% Coinsurance after deductible
100% Coinsurance
Specialty drugs
40% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
40% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
40% Coinsurance after deductible
100% Coinsurance
Emergency Room Services
$75 Copay with deductible
40% Coinsurance after deductible
40% Coinsurance after deductible
$75 Copay with deductible
40% Coinsurance after deductible
40% Coinsurance after deductible
Emergency Transportation/Ambulance
40% Coinsurance after deductible
40% Coinsurance after deductible
Urgent Care
$50 Copay
$50 Copay
Inpatient Hospital Services
$150 Copay per stay with deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
40% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Outpatient Services
40% Coinsurance after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$150 Copay per stay with deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
40% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$150 Copay per stay with deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
100% Coinsurance
Prenatal and postnatal care
40% Coinsurance after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$150 Copay with deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
100% Coinsurance
Home Healthcare Services
40% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
40% Coinsurance after deductible
100% Coinsurance
Habilitation Services
40% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
40% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
40% Coinsurance after deductible
100% Coinsurance
Hospice Services
40% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
40% Coinsurance after deductible
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
40% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
40% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
40% Coinsurance after deductible
100% Coinsurance
Diabetes Education
$75 Copay
100% Coinsurance
Nutritional Counseling
40% Coinsurance after deductible
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
$75 Copay
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
40% Coinsurance after deductible
100% Coinsurance
Dental Check Up (Child)
No Charge
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance after deductible
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered