Anthem Silver Pathway X Enhanced 4500/20% HSA

Anthem Blue Cross and Blue Shield

SilverHSA eligible

Ind. deductible: $4,500
Family deductible: $4,500
Ind. OOP max: $6,000
Family OOP max: $6,000

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$349	—
30	$396	—
40	$445	—
50	$622	—
60	$946	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	20.00% Coinsurance after deductible

Specialist

Benefit	In-network
Specialist Visit	0.00%

Hospital

Benefit	In-network
Emergency Room Services	20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	20.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	20.00% Coinsurance after deductible
Urgent Care Centers or Facilities	20.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	20.00% Coinsurance after deductible
Non-Preferred Brand Drugs	0.00%
Preferred Brand Drugs	20.00% Coinsurance after deductible
Specialty Drugs	40.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	20.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	20.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	20.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	20.00% Coinsurance after deductible
Bariatric Surgery	20.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	20.00% Coinsurance after deductible
Chiropractic Care	20.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	20.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Education	20.00% Coinsurance after deductible
Dialysis	20.00% Coinsurance after deductible
Durable Medical Equipment	20.00% Coinsurance after deductible
Emergency Transportation/Ambulance	0.00%
Eye Glasses for Children	$0.00
Habilitation Services	20.00% Coinsurance after deductible
Hearing Aids	20.00% Coinsurance after deductible
Home Health Care Services	20.00% Coinsurance after deductible
Hospice Services	20.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	20.00% Coinsurance after deductible
Infertility Treatment	0.00%
Infusion Therapy	0.00%
Inpatient Physician and Surgical Services	0.00%
Laboratory Outpatient and Professional Services	20.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	20.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	20.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	20.00% Coinsurance after deductible
Outpatient Rehabilitation Services	0.00%
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	Not covered
Prosthetic Devices	20.00% Coinsurance after deductible
Radiation	20.00% Coinsurance after deductible
Reconstructive Surgery	20.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	20.00% Coinsurance after deductible
Rehabilitative Speech Therapy	20.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	20.00% Coinsurance after deductible
Skilled Nursing Facility	20.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	20.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	20.00% Coinsurance after deductible
Transplant	20.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	0.00%
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	20.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.