Bronze HMO Pathway Enhanced Tiered

86545CT1230013
Expanded Bronze
HMO

Bronze HMO Pathway Enhanced Tiered is an Expanded Bronze HMO plan by Anthem Blue Cross and Blue Shield.

Locations

Bronze HMO Pathway Enhanced Tiered is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Bronze HMO Pathway Enhanced Tiered 86545CT1230013.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 86545CT1230013

Cost-Sharing Overview

Bronze HMO Pathway Enhanced Tiered 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 Bronze HMO Pathway Enhanced Tiered?

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

Bronze HMO Pathway Enhanced Tiered 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 Bronze HMO Pathway Enhanced Tiered 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

Bronze HMO Pathway Enhanced Tiered includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Maximum of 2 daily copays per in network admission for a maximum of $1000. Copay applies after deductible has been met.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Maximum of 2 daily copays per in network admission for a maximum of $1000. Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met. Maximum of 2 daily copays per in network admission for a maximum of $1000. Copay applies after deductible has been met.
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Benefits for non-Emergency ambulance services will be limited to $50K per occurrence if an OON Provider is used.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Visit(s) per Year Subject to a separate $50 deductible for in networkSubstantially Equal
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No The coinsurance for prosthetic arms, or legs, including one with a microprocessor if medically necessary cannot exceed 20%.
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Maximum of 2 daily copays per in network admission for a maximum of $1000. Copay applies after deductible has been met. Hospice Bereavement is not covered.  Life Expectancy of 6 months or less and if the care is Pre-Authorized or Pre-Certified.
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Maximum of 2 daily copays per in network admission for a maximum of $1000. Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met. Maximum of 2 daily copays per in network admission for a maximum of $1000. Copay applies after deductible has been met.
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year Substantially Equal
Treatment of Medical Complications of Alcoholism
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered for pain management onlyAdditional EHB Benefit
Mammography Ultrasound
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year Additional EHB Benefit
Bones/Joints
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.Additional EHB Benefit
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Includes coverage for Breast Tomosynthesis
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No When approved by Anthem, your coverage includes benefits for unrelated donor searches for bone marrow/stem cell transplants performed by an authorized and licensed registry for a Covered Transplant Procedure up to $30,000. Transplant benefits are combined for both INN & ONN.
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.Not EHB
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 2 Years Limited to 1 per ear per member every 2 yearsSubstantially Equal
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or for Home Delivery. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met. Site of Service: Up to $65 Copayment per service after the in-network plan Deductible is met up to a combined annual maximum of $375 for MRI and CAT Scans; $400 for PET scans
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No10 Hours per Lifetime If needed carrier may develop explanations pertinent in defining the benefit attributes. AHCT disagrees the limit is per life time. The limit per the document is up to 10 hrs initial training and up to 8 additional hrs under other circumstances.Substantially Equal
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Maximum of 2 daily copays per in network admission for a maximum of $1000. Copay applies after deductible has been met.
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Wound Care for Individuals with Epidermolysis Bullosa
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Year Substantially Equal
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Bone Marrow Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.Additional EHB Benefit
Diabetes Care Management
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Ingestion of a Controlled Drug
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Post-Mastectomy Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Developmental Needs of Children & Youth with Cancer
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year For Illnesses requiring therapeutic dietary monitoring, including the diagnosis of obesity limited to 2 visits per year.Substantially Equal
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met. Benefit limited to the following lifetime cycles: 4 cycles for ovulation induction, 3 cycles for intrauterine insemination, 2 cycles combined for in-vitro fertilization, GIFT, ZIFT, and Low Tubal Ovum Transfer.
Early Intervention Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No90 Days per Year Substantially Equal
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Visit(s) per Year Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.Substantially Equal
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Emergency Room copay is waived if directly admitted to the hospital.
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Tier 1 beneifts are subject to a lower cost share after the in-network deductible is met.
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 30 day supply for Retail or 90 day supply for Home Delivery. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Visit(s) per Year 40 visits per person per year for Physical/Occupational/Speech Therapies combined. Medically necessary treatment of Autism Spectrum Disorder is covered. Limitations do not apply to Autism Spectrum Disorder diagnosis.Substantially Equal
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Medically necessary services only
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following Bronze HMO Pathway Enhanced Tiered 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 Bronze HMO Pathway Enhanced Tiered?

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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