Anthem Silver Pathway Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs)

49046GA0410168
Silver
HMO

Anthem Silver Pathway Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs) is a Silver HMO plan by Anthem Blue Cross and Blue Shield.

IMPORTANT: You are viewing the 2024 version of Anthem Silver Pathway Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs) 49046GA0410168. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Anthem Silver Pathway Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Anthem Silver Pathway Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs) 49046GA0410168.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 49046GA0410168

Cost-Sharing Overview

Anthem Silver Pathway Guided Access HMO 5500($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 Silver Pathway Guided Access HMO 5500($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 Silver Pathway Guided Access HMO 5500($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: Yes
Specialist Requiring Referral: You need a Referral or approval from your Primary Care doctor to see all specialists except for an Obstetrician/Gynecologist (OB/GYN), Dermatologist, Mental Health, Substance Abuse, Chiropractor 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 Silver Pathway Guided Access HMO 5500($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 Silver Pathway Guided Access HMO 5500($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
$20.00 Not ApplicableNot Applicable 100.00% Primary Care Office visits, Other Practitioners Office visits, and Virtual Office visits have a combined shared limit of 3 copays before deductible/coinsurance applies. 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 or website.
Specialist Visit
Covered
$80.00 Not ApplicableNot 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 mobile app or website.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 Not ApplicableNot 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 mobile app or website.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 25.00% 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
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$75.00 Not Applicable$75.00 Not Applicable Additional Cost Share determined based on service received
Home Health Care Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%120.0 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
$750.00 Copay after deductible 25.00% Coinsurance after deductible$750.00 Copay after deductible 25.00% Coinsurance after deductible Copayment (if applicable) is waived if admitted.
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services.
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services. 60 Days per year.
Prenatal and Postnatal Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 100.00% 30 day retail supply
Preferred Brand Drugs
Covered
$40.00 Not ApplicableNot Applicable 100.00% 30 day retail supply
Non-Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% 30 day retail supply
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% 30 day supply
Outpatient Rehabilitation Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy.
Habilitation Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Applied Behavioral Analysis services are subject to medical necessity and will require an authorization.
Chiropractic Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%20.0 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
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Hearing Aids covered In-Network only for ages 1- 18 only. Limit 1 per ear every 48 months with a $3000 cap per ear every 48 months.
Hearing Aids
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Limited to a maximum of $3,000 for each hearing impaired ear through age 18 and for the replacement of one hearing aid per hearing impaired ear every 48 months
Imaging (CT/PET Scans, MRIs)
Covered
$300.00 Copay after deductible 50.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
$80.00 Not ApplicableNot Applicable 100.00%4.0 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 Not ApplicableNot Applicable 100.00%1.0 Visit(s) per Year 1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year 1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge after deductible Not ApplicableNot Applicable 100.00%2.0 Visit(s) per Year 2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy.?
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Year 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00% Care provided for birth through age 5.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Basic Dental Care – Child
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Orthodontia – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Medically Necessary Orthodontia only
Major Dental Care – Child
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
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
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%10000.0 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
$80.00 Not ApplicableNot Applicable 100.00% Cost share is driven by provider/setting.
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Allergy Testing
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Diabetes Education
Covered
$80.00 Not ApplicableNot Applicable 100.00% Cost share is driven by provider/setting.
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Wigs are limited to 1 (one) per year as needed after cancer treatment.?
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% Cost share is driven by provider/setting.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%4.0 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Care Management
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Off Label Prescription Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Well Child Care
Covered
No Charge No ChargeNot Applicable 100.00%
Bone Marrow Testing
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%10000.0 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
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%10000.0 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 Silver Pathway Guided Access HMO 5500($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 Silver Pathway Guided Access HMO 5500($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 Silver Pathway Guided Access HMO 5500($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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