Anthem Bronze Pathway X HMO 4900
| Plan Type: | HMO |
| Plan Tier: | Expanded Bronze |
| Individual Deductible | $4,900 |
| Family Deductible | $9,800 |
| Individual Out of Pocket Max | $8,550 |
| Family Out of Pocket Max | $17,100 |
| Primary Care Visit: | $50 |
| Specialist Visit: | 30% Coinsurance after deductible |
| Emergency Room: | $500 Copay after deductible and 30% Coinsurance after deductible |
| Hospital - Physician: | 30% Coinsurance after deductible |
| Hospital - Facility: | $500 Copay per Stay after deductible and 50% Coinsurance after deductible |
| Link to Full SBC: | https://www.sbc.anthem.com/dps/ccd5K55 |
| Plan Brochure: | http://editiondigital.net/view/IU65/2021/ON_HIX_GA_KIT_2021 |
Other Coverage:
| Child Dental: | Yes |
| Adult Dental | No |
Prescription Drug Pricing:
| Generic Drugs: | $30 |
| Non-Preferred Brand Drugs: | 40% Coinsurance after deductible |
| Preferred Brand Drugs: | 30% Coinsurance after deductible |
| Specialty Drugs: | 40% Coinsurance after deductible |
| Summary of Benefits | https://www.anthem.com/GASelectdrugtier4 |
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