Gold HMO Pathway Enhanced Tiered

86545CT1230016
Gold
HMO

Gold HMO Pathway Enhanced Tiered is a Gold HMO plan by Anthem Blue Cross and Blue Shield.

Locations

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

Plan Overview

This is a plan overview for 2022 version of Gold HMO Pathway Enhanced Tiered 86545CT1230016.
Insurer: Anthem Blue Cross and Blue Shield
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 86545CT1230016

Cost-Sharing Overview

Gold 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 Gold 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

Gold 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 Gold 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

Gold 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
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
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered for pain management onlyAdditional EHB Benefit
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
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Visit(s) per Year Substantially Equal
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Donor search charges are limited to 10 best matched donors identified by an authorized registry.
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No90 Days per Year Substantially Equal
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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 years. Limits are combined for INN and OON.Substantially Equal
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
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. Cost share shown is for a 30 day supply.
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
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. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Routine Dental Services (Adult)
Not 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
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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. Cost share shown is for a 30 day supply.
Early Intervention Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
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 Exam(s) per Year Substantially Equal
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No10 Hours per Lifetime Benefits are provided for 10 hours of initial training, 4 hours of additional training because of changes in the individual’s condition and four hours of training required by new developments in the treatment of diabetes.Substantially Equal
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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.
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mammography Ultrasound
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
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.
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
Accidental Ingestion of a Controlled Drug
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment of Medical Complications of Alcoholism
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
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. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member coinsurance will not exceed the Primary Care Provider cost share.
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.
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
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
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Member coinsurance will not exceed the Primary Care Provider cost share.
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
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year 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
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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.
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Medically necessary services only
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
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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. Site of Service: $10 Copayment per service after the in-network plan Deductible is met
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 $75 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
Mental/Behavioral Health Inpatient Services
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. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
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. Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence.
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Diabetes Care Management
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%.
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Includes coverage for Breast Tomosynthesis
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
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.
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
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. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Wound Care for Individuals with Epidermolysis Bullosa
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
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.
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Hospice Bereavement is not covered. Life Expectancy of 12 months or less and if the care is Pre-Authorized or Pre-Certified.
Major Dental Care – Child
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
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
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.
Specialty 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. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Orthodontia – Adult
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 Up to a combined annual maximum cost share of $375 for MRI and CAT scans; $400 for PET scans.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Post-Mastectomy Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold 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 Gold 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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