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Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs)

17575IN0700053
Expanded Bronze
HMO

Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) is an Expanded Bronze HMO plan by Anthem Blue Cross and Blue Shield.

IMPORTANT: You are viewing the 2024 version of Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) 17575IN0700053. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) 17575IN0700053.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 17575IN0700053

Cost-Sharing Overview

Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Urgent/Emergency Coverage Only
Out of Service Area Coverage: No
Out of Service Area Coverage Description: TRAD/PAR network
National Network: No

Additional Benefits and Cost-Sharing

Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$0.00 50.00% Coinsurance after deductibleNot Applicable 100.00% First 3 visits subject to copay. Visits 4+ subject to deductible and coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.
Specialist Visit
Covered
$60.00 50.00% Coinsurance after deductibleNot Applicable 100.00% You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 50.00% Coinsurance after deductibleNot Applicable 100.00% First 3 visits subject to copay. Visits 4+ subject to deductible and coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%82.0 Visit(s) per Year Private Duty Nursing care provided in home setting is limited to a maximum of 82 visits per Member, per Calendar Year and a maximum of 164 visits per Member, per lifetime.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$95.00 Not Applicable$95.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%100.0 Visit(s) per Benefit Period Combined In and out of network. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.
Emergency Room Services
Covered
$500.00 Copay after deductible 50.00% Coinsurance after deductible$500.00 Copay after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$1500.00 Copay per Stay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00% Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Benefit Period Limit is combined both In and Out of Network.
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$1500.00 Copay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share driven by provider/setting.
Mental/Behavioral Health Inpatient Services
Covered
$1500.00 Copay per Stay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share driven by provider/setting.
Substance Abuse Disorder Inpatient Services
Covered
$1500.00 Copay per Stay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Cost share shown is for a 30 day supply.
Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Cost share shown is for a 30 day supply.
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share shown is for a 30 day supply.
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share shown is for a 30 day supply.
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are not combined but separate based on determination of Habilitative Service or Rehabilitative Service) for both in and out of network services.. The limits do not apply to Mental Health and Substance Abuse conditions.
Chiropractic Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%12.0 Visit(s) per Benefit Period Limit combined In and out of network. Cost share driven by provider/setting.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% One wig per benefit period combined both In and Out of Network. Network and Non-Network for wigs following cancer treatment.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 100.00% You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(s) per Benefit Period Eye exams are covered once per benefit period for In Network Services.
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year Eye glasses are covered once per benefit period for In Network Services.
Dental Check-Up for Children
Covered
No Charge after deductible Not ApplicableNot Applicable 100.00%2.0 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period Combined In and out of network. Cost share driven by provider/setting.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Benefit Period Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Both apply to In-Network Providers and Non-Network Providers combined. Coverage also includes an additional 20 visits each for habilitative services.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00% Cost share shown is for a 30 day supply.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share driven by provider/setting.
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share driven by provider/setting.
Basic Dental Care – Child
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Major Dental Care – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
$1500.00 Copay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00% Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined).
Accidental Dental
Covered
$60.00 50.00% Coinsurance after deductibleNot Applicable 100.00%3000.0 Dollars per Episode The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$60.00 50.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Must be medically necessary.
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).
Nutritional Counseling
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share driven by provider/setting.
Reconstructive Surgery
Covered
$1500.00 Copay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00% Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.
Gender Affirming Care
Dental Anesthesia
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Limited to Accidental Dental or a Member less than 19 years of age or a Member with intellectual or physical disability, are covered if the Member requires dental treatment to be given in a Hospital or Outpatient Ambulatory Surgical Facility.

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Anthem Bronze Pathway Essentials 4500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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