Anthem Bronze Pathway X HMO 9100/0% Standard
29276OH0920431
Bronze
HMO
Anthem Bronze Pathway X HMO 9100/0% Standard is a Bronze HMO plan by Anthem Blue Cross and Blue Shield.
IMPORTANT: You are viewing the 2023 version of Anthem Bronze Pathway X HMO 9100/0% Standard 29276OH0920431. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Anthem Bronze Pathway X HMO 9100/0% Standard is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Anthem Bronze Pathway X HMO 9100/0% Standard 29276OH0920431.
| Insurer: | Anthem Blue Cross and Blue Shield |
| Network Type: | HMO |
| Metal Type: | Bronze |
| HSA Eligible?: | No |
| Plan ID: | 29276OH0920431 |
Cost-Sharing Overview
Anthem Bronze Pathway X HMO 9100/0% Standard offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Anthem Bronze Pathway X HMO 9100/0% Standard includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $9,100.00 | $9100 per person | $18200 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Anthem Bronze Pathway X HMO 9100/0% Standard will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $9,100.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $5,400.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 X HMO 9100/0% Standard?
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 X HMO 9100/0% Standard 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 X HMO 9100/0% Standard 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 X HMO 9100/0% Standard 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 | No Charge after deductible | 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. |
| Specialist Visit Covered | No Charge after deductible | 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 | No Charge after deductible | 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. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | No Charge after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | No Charge after deductible | 100.00% | |
| Hospice Services Covered | No Charge after deductible | 100.00% | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | No Charge after deductible | 100.00% | Includes services to diagnose and treat MEDICAL conditions resulting in infertility. Excludes: Artificial insemination, in vitro fertilization, other types of artificial or surgical means of conception including drugs administered in connection with these procedures. |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | No Charge after deductible | 100.00% | 90 Visit(s) per Year Private Duty Nursing is only covered through Home Health Care Services and is limited to 90 visits per calendar year. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | No Charge after deductible | 100.00% | Urgent Care center services received outside of the service area are not covered, unless the service is rendered at a BlueCard facility. If out of area Urgent Care services are rendered at a BlueCard facility, the cost share is the same as In Network. |
| Home Health Care Services Covered | No Charge after deductible | 100.00% | 100 Visit(s) per Year Benefit limit does not apply to Home Infusion Therapy or Home Dialysis.? Private Duty Nursing is only covered through Home Health Care Services and is limited to 90 visits per calendar year, which is separate from the 100 visits a year limit for “other” Home Health Care services. Benefit limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health. |
| Emergency Room Services Covered | No Charge after deductible | No Charge after deductible | Copay waived if admitted. |
| Emergency Transportation/Ambulance Covered | No Charge after deductible | No Charge after deductible | Nonemergency Ambulance Services must be Preauthorized by Us. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | No Charge after deductible | 100.00% | Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) is limited to a maximum of 60 days per member, per calendar year. Coverage includes inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is medically necessary. |
| Inpatient Physician and Surgical Services Covered | No Charge after deductible | 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | No Charge after deductible | 100.00% | 90 Days per Year Custodial or residential care in a skilled nursing facility or any other facility is not covered except when rendered as part of hospice care. |
| Prenatal and Postnatal Care Covered | No Charge after deductible | 100.00% | Services related to surrogacy are excluded if the member is not the surrogate. |
| Delivery and All Inpatient Services for Maternity Care Covered | No Charge after deductible | 100.00% | Coverage includes inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. Covered services include at-home post delivery care visits at your residence by a Physician or Nurse performed no later than 72 hours following you and your newborn child?s discharge from the hospital. |
| Mental/Behavioral Health Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Generic Drugs Covered | No Charge after deductible | 100.00% | Cost share reflects a 30 day retail supply. |
| Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | Cost share reflects a 30 day retail supply |
| Non-Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | Cost share reflects a 30 day retail supply |
| Specialty Drugs Covered | No Charge after deductible | 100.00% | Cost share reflects a 30 day retail supply |
| Outpatient Rehabilitation Services Covered | No Charge after deductible | 100.00% | 116 Visit(s) per Year 20 visits each Physical Therapy, Occupational Therapy, Speech Therapy, Pulmonary Rehabilitation. 36 visits for Cardiac Rehabilitation. Limit is combined across professional visits and outpatient facilities. |
| Habilitation Services Covered | No Charge after deductible | 100.00% | Benefits include treatment of Autism Spectrum disorder for children ages 0-21. Applied Behavioral Analysis is limited to 20 hours per week. Limit is combined across professional visits and outpatient facilities. |
| Chiropractic Care Covered | No Charge after deductible | 100.00% | 12 Visit(s) per Year Limit is combined across professional visits and outpatient facilities for Osteopathic/Chiropractic Manipulation Therapy. These services are not covered in the home. |
| Durable Medical Equipment Covered | No Charge after deductible | 100.00% | Wigs are limited to 1 wig per Member, per Benefit Period after cancer treatment. Coverage includes 4 surgical bras per benefit period. |
| Hearing Aids Not Covered | Cochlear implants are covered as durable medical equipment (DME). | ||
| Imaging (CT/PET Scans, MRIs) Covered | No Charge after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | 0.00% | 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 Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge | 100.00% | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | No Charge | 100.00% | 1 Item(s) per Year |
| Dental Check-Up for Children Covered | No Charge after deductible | 100.00% | 2 Visit(s) per Year |
| Rehabilitative Speech Therapy Covered | No Charge after deductible | 100.00% | 20 Visit(s) per Year Autism limits are separate from Rehabilitation limits for Physical and Speech Therapy. Limit is combined across professional visits and outpatient facilities. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | No Charge after deductible | 100.00% | 40 Visit(s) per Year 20 visits per person per year for Physical Therapy and a separate 20 visits for Occupational Therapies. Autism limits are separate from Rehabilitation limits for Physical and Speech Therapy. Limit is combined across professional visits and outpatient facilities. |
| Well Baby Visits and Care Covered | No Charge | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | No Charge after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | No Charge after deductible | 100.00% | |
| Basic Dental Care – Child Covered | 40.00% Coinsurance after deductible | 100.00% | |
| Orthodontia – Child Covered | 50.00% Coinsurance after deductible | 100.00% | |
| Major Dental Care – Child Covered | 50.00% Coinsurance after deductible | 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 | no coverage except limited to therapeutic coverage (only in case of rape, incest or health of mother) | ||
| Transplant Covered | No Charge after deductible | 100.00% | Transportation and lodging limited to $10000/transplant per benefit paid. The Plan will provide assistance with reasonable and necessary travel expenses when patient is required to travel more than 75 miles from residence to reach the facility where the Covered Transplant Procedure will be performed. If the Member receiving treatment is a minor, then reasonable and necessary expenses for transportation and lodging may be allowed for two companions. Unrelated Donor Search is Limited to a maximum of the 10 best matched donors, identified by an authorized registry |
| Accidental Dental Covered | No Charge after deductible | 100.00% | 3000 Dollars per Episode Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered. Cost share will vary by the specific service rendered. Accident must have occurred on or after your effective date and treatment within 12 months of an accidental injury. |
| Dialysis Covered | No Charge after deductible | 100.00% | |
| Allergy Testing Covered | No Charge after deductible | 100.00% | |
| Chemotherapy Covered | No Charge after deductible | 100.00% | Cost share will vary by the specific service rendered. |
| Radiation Covered | No Charge after deductible | 100.00% | |
| Diabetes Education Covered | No Charge after deductible | 100.00% | |
| Prosthetic Devices Covered | No Charge after deductible | 100.00% | Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part. |
| Infusion Therapy Covered | No Charge after deductible | 100.00% | Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy. Home Infusion Therapy is not included in the Home Health Care visit maximum |
| Treatment for Temporomandibular Joint Disorders Covered | No Charge after deductible | 100.00% | |
| Nutritional Counseling Covered | No Charge after deductible | 100.00% | Covered benefit under Home Health Services or covered as US Preventive Services Task Force (USPSTF) A or B recommendation under preventive health services, which includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors. |
| Reconstructive Surgery Covered | No Charge after deductible | 100.00% | Cost shares may vary based on the setting in which Covered Services are received. |
| Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following Anthem Bronze Pathway X HMO 9100/0% Standard 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Anthem Bronze Pathway X HMO 9100/0% Standard 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 X HMO 9100/0% Standard?
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