Anthem Silver Mountain Enhanced X HMO 5000

76680CO0220040
Silver
HMO

Anthem Silver Mountain Enhanced X HMO 5000 is a Silver HMO plan by Anthem Blue Cross and Blue Shield.

Locations

Anthem Silver Mountain Enhanced X HMO 5000 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Anthem Silver Mountain Enhanced X HMO 5000 76680CO0220040.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 76680CO0220040

Cost-Sharing Overview

Anthem Silver Mountain Enhanced X HMO 5000 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 Silver Mountain Enhanced X HMO 5000?

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 Silver Mountain Enhanced X HMO 5000 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Low Back Pain, High Blood Pressure & High Cholesterol
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 Silver Mountain Enhanced X HMO 5000 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Anthem Silver Mountain Enhanced X HMO 5000 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Intensive Outpatient for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Item(s) per Year Additional EHB Benefit
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Substance Use Disorder Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Prosthetics: Legs and Arms
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Deductible not to exceed Medicare Part B deductibleAdditional EHB Benefit
Partial Hospitalization for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Cost share shown is for a 30-day supply.
Private-Duty Nursing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Inpatient Rehabilitation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Item(s) per Year Additional EHB Benefit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Item(s) per Year 20 visits for Physical Therapy/ 20 visits for Occupational Therapy/ 20 visits for Speech TherapyAdditional EHB Benefit
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Cost share shown is for a 30-day supply.
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Telehealth Specialist
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year Coverage restrictions apply-See contract details.
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Item(s) per Year
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Autism Spectrum Disorders – Assessment and Evaluation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Telehealth Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Accidental Dental
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Applied Behavior Analysis Based Therapies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Occupational Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year Additional EHB Benefit
Partial Hospitalization for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Year Substantially Equal
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No28 Item(s) per Year
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Postpartum Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Postpartum Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Mental/Behavioral Health Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Residential Day Treatment for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Residential Day Treatment for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Telehealth Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Cost share shown is for a 30-day supply.
Telehealth PCP
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Coverage restrictions apply-See contract details.
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year Additional EHB Benefit
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Covered up to age 18; supplied every 5 years.
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Item(s) per Year Substantially Equal
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Item(s) per Year 20 visits for Physical Therapy/ 20 visits for Occupational Therapy/ 20 visits for Speech Therapy
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year
Intensive Outpatient for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Cost share shown is for a 30-day supply.

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem Silver Mountain Enhanced X HMO 5000 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.

Ready to sign up for Anthem Silver Mountain Enhanced X HMO 5000?

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

Table of Contents