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Anthem Gold Pathway X Guided Access HMO 2000/25% Standard

49046GA0410187
Gold
HMO

Anthem Gold Pathway X Guided Access HMO 2000/25% Standard is a Gold HMO plan by Blue Cross Blue Shield Healthcare Plan of Georgia.

IMPORTANT: You are viewing the 2023 version of Anthem Gold Pathway X Guided Access HMO 2000/25% Standard 49046GA0410187. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Anthem Gold Pathway X Guided Access HMO 2000/25% Standard is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Anthem Gold Pathway X Guided Access HMO 2000/25% Standard 49046GA0410187.
Insurer: Blue Cross Blue Shield Healthcare Plan of Georgia
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 49046GA0410187

Cost-Sharing Overview

Anthem Gold Pathway X Guided Access HMO 2000/25% Standard 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 Gold Pathway X Guided Access HMO 2000/25% 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 Gold Pathway X Guided Access HMO 2000/25% 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: Yes
Specialist Requiring Referral: You do not need a Referral or approval from Your PCP to see an Obstetrician/Gynecologist (OB/GYN), Dermatologist, or eye care professionals including Optometrists and Ophthalmologists.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Anthem Gold Pathway X Guided Access HMO 2000/25% 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 Gold Pathway X Guided Access HMO 2000/25% 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
$30.00 100.00% 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 mobile app, website, or Anthem-enabled devices
Specialist Visit
Covered
$60.00 100.00% 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 mobile app, website, or Anthem-enabled devices
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00% 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 mobile app, website, or Anthem-enabled devices
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 $45.00 Additional Cost Share determined based on service received
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%120 Visit(s) per Year Limit also applies to Physical, Occupational or Speech Therapy when performed as part of Home Health Care Services.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Copayment (if applicable) is waived if admitted.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible NON-emergency ambulance/transportation out of network is NOT covered, unless prior authorization is obtained. If authorized out of network, limited to $50,000 per occurrence.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00% Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
25.00% Coinsurance after deductible 100.00% Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan.
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Year Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services. 60 Days per year.
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00% Cost share is driven by provider/setting.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00% Cost share is driven by provider/setting.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00% 30 day retail supply
Preferred Brand Drugs
Covered
$30.00 100.00% 30 day retail supply
Non-Preferred Brand Drugs
Covered
$60.00 100.00% 30 day retail supply
Specialty Drugs
Covered
$250.00 100.00% 30 day supply
Outpatient Rehabilitation Services
Covered
$30.00 100.00%20 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis.
Habilitation Services
Covered
$30.00 100.00%20 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis. Plans will include Applied Behavioral Analysis (ABA) services with no visit max for In-Network services for children ages 0-20 with ASD diagnosis. ABA services are subject to medical necessity and will require an authorization.
Chiropractic Care
Covered
$30.00 100.00%20 Visit(s) per Year Visit limit is combined both across outpatient and other professional visits. Cost share is driven by provider/setting. 20 Visits per year.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00% Hearing Aids covered In-Network only for under age 18 only. Limit 1 per ear every 48 months with a $3000 cap per ear every 48 months.
Hearing Aids
Covered
25.00% Coinsurance after deductible 100.00% Benefit is covered for members through age 18. Limited to $3000 per ear every 48 months.
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
$60.00 100.00%4 Visit(s) per Year Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(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
$30.00 100.00%20 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy.? Speech Therapy?limits will not apply for children ages 0-20 ?with Autism (ASD) diagnosis.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%20 Visit(s) per Year 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis.
Well Baby Visits and Care
Covered
No Charge 100.00% Care provided for birth through age 5.
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Basic Dental Care – Child
Covered
No Charge after deductible 100.00%
Orthodontia – Child
Covered
No Charge after deductible 100.00% Medically Necessary Orthodontia only
Major Dental Care – Child
Covered
No Charge 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
Transplant
Covered
25.00% Coinsurance after deductible 100.00%10000 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Accidental Dental
Covered
$60.00 100.00% Cost share is driven by provider/setting.
Dialysis
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Radiation
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Diabetes Education
Covered
$60.00 100.00% Cost share is driven by provider/setting.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00% Wigs are limited to 1 (one) per year as needed after cancer treatment.?
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00% Cost share is driven by provider/setting.
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$30.00 100.00%4 Visit(s) per Year Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan.
Gender Affirming Care
Clinical Trials
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
$60.00 100.00%
Off Label Prescription Drugs
Covered
$250.00 100.00%
Well Child Care
Covered
No Charge 100.00%
Bone Marrow Transplant
Covered
25.00% Coinsurance after deductible 100.00%10000 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.
Heart Transplant
Covered
25.00% Coinsurance after deductible 100.00%10000 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem Gold Pathway X Guided Access HMO 2000/25% 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.

Additional Resources

Below are additional resources for Anthem Gold Pathway X Guided Access HMO 2000/25% 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 Gold Pathway X Guided Access HMO 2000/25% 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

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