Anthem Silver Pathway/Lean 5800/40% Standard

79475WI0340170
Silver
HMO

Anthem Silver Pathway/Lean 5800/40% Standard is a Silver HMO plan by Anthem Blue Cross and Blue Shield.

IMPORTANT: You are viewing the 2023 version of Anthem Silver Pathway/Lean 5800/40% Standard 79475WI0340170. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Anthem Silver Pathway/Lean 5800/40% Standard is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Anthem Silver Pathway/Lean 5800/40% Standard 79475WI0340170.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 79475WI0340170

Cost-Sharing Overview

Anthem Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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
$40.00 100.00% Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are 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
$80.00 100.00% Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are 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.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00% Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are 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
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% 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
$60.00 $60.00
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%60 Visit(s) per Year
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible If applicable, copay waived if admitted.
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% 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
40.00% Coinsurance after deductible 100.00% Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) ? Limited to a maximum of 60 days per Member, per Calendar Year.
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 100.00%30 Days per Admission
Prenatal and Postnatal Care
Covered
40.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 100.00% Excludes services related to surrogacy if member is not the surrogate.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% 30 day supply retail
Preferred Brand Drugs
Covered
$40.00 100.00% 30 day supply retail
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% 30 day supply retail
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% 30 day supply retail
Outpatient Rehabilitation Services
Covered
$40.00 100.00%60 Visit(s) per Year 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy
Habilitation Services
Covered
$40.00 100.00%60 Visit(s) per Year 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy
Chiropractic Care
Covered
$40.00 100.00% Member is responsible for the Primary Care Physician cost share amount when service is performed by a Primary Care Physician or Chiropractor.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years Limited to a single purchase of a type of Durable Medical Equipment/Prosthetic (including repair and replacement) every 3 years.
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years 1 hearing aid per ear every 3 years
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance 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. Covered Services also include lead poisoning screening for Dependents under age six (6), as required by state law.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
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
$40.00 100.00%20 Visit(s) per Year Limit is combined across professional visits and outpatient facilities.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%40 Visit(s) per Year 20 visits each Physical Therapy/Occupational Therapy per year. Limit is combined across professional visits and outpatient facilities.
Well Baby Visits and Care
Covered
No Charge 100.00% Benefits are covered under preventive care.
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance 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
Limited to therapeutic (only in case of rape, incest or health of mother)
Transplant
Covered
40.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
$80.00 100.00%3000 Dollars per Episode Limited to $900 per tooth
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Not Covered
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$80.00 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years Limit is applicable to a single purchase of a type of prosthetic device. Limit does not apply to prosthetics required by the Women?s Health and Cancer Rights Act of 1998.
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% Coinsurance after deductible 100.00% Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth (braces), repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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 Silver Pathway/Lean 5800/40% 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

Table of Contents