Anthem Silver Pathway X 5800/40% Standard

32753MO0950022
Silver
EPO

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

IMPORTANT: You are viewing the 2023 version of Anthem Silver Pathway X 5800/40% Standard 32753MO0950022. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

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

Plan Overview

This is a plan overview for 2023 version of Anthem Silver Pathway X 5800/40% Standard 32753MO0950022.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 32753MO0950022

Cost-Sharing Overview

Anthem Silver Pathway X 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 X 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 X 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 X 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: BlueCard PPO Basic Network
National Network: No

Additional Benefits and Cost-Sharing

Anthem Silver Pathway X 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
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
50.00% 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
Transplant
Covered
40.00% Coinsurance after deductible 100.00% Includes coverage for travel/lodging as approved by the plan ($10,000 per transplant). Donor search charges are limited to 10 best matched donors identified by an authorized registry.
Accidental Dental
Covered
$80.00 100.00%3000 Dollars per Episode
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
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% Benefits include the purchase, fitting, adjustments, repairs and replacements.
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, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).
Nutritional Counseling
Covered
$40.00 100.00%
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00% Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00% 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 Sydney application.
Specialist Visit
Covered
$80.00 100.00% 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 Sydney application.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00% 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 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
Covered
40.00% Coinsurance after deductible 100.00%82 Visit(s) per Year Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.
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%100 Visit(s) per Year Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible Emergency Room copay is waived if directly admitted to the hospital.
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 prior authorization is obtained from Anthem. 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 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%150 Days per Year Limited to 150 combined days per calendar year for Physical Medicine, Rehabilitation and Skilled Nursing Facility services.
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%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 $40.00 Limitation of Two office visits per member per Year with a Non-Network licensed provider.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 $40.00 Limitation of Two office visits per member per Year with a Non-Network licensed provider.
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% Cost share shown is for a 30 day supply.
Preferred Brand Drugs
Covered
$40.00 100.00% Cost share shown is for a 30 day supply.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00% Cost share shown is for a 30 day supply.
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00% Cost share shown is for a 30 day supply.
Outpatient Rehabilitation Services
Covered
$40.00 100.00%40 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.
Habilitation Services
Covered
$40.00 100.00%40 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.
Chiropractic Care
Covered
$40.00 100.00%26 Visit(s) per Year Chiropractic Manipulation Therapy visits beyond the 26 visit limit require Prior Authorization from Anthem in order to be covered.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40.00% Coinsurance after deductible 100.00% One hearing aid per ear every 36 months. Limit does not apply to newborn.
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. Immunizations prior to 6th birthday covered in full.
Routine Foot Care
Covered
$80.00 100.00% Coverage is available if Medically Necessary Services
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%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%40 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.
Well Baby Visits and Care
Covered
No Charge 100.00%
Gender Affirming Care
Not Covered
Clinical Trials
Covered
40.00% Coinsurance after deductible 100.00%
Inherited Metabolic Disorder – PKU
Covered
$80.00 Copay after deductible 100.00%
Dental Anesthesia
Covered
40.00% Coinsurance after deductible 100.00% Benefits are provided only for the administration of general anesthesia and for both facility and professional charges occurring in connection with dental services, regardless of age, when prior authorization for an inpatient dental care procedure is approved by us. In addition, and as required by law, benefits for the administration of general anesthesia, including facility and professional charges, are provided for the following Members: ? A Member through the age of four; ? A Member who is severely disabled; and ? A Member who has a medical or behavioral condition that requires hospitalization or general anesthesia when dental services are provided.
Bone Marrow Testing
Covered
40.00% Coinsurance after deductible 100.00%
Newborn Hearing Screening
Covered
40.00% Coinsurance after deductible 100.00%
Applied Behavior Analysis Based Therapies
Covered
40.00% Coinsurance after deductible 100.00% Limited to members through 18 years of age.

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem Silver Pathway X 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 X 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 X 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

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