Anthem Silver Preferred Blue PPO 4000/10%/7250 w/HSA

Anthem Blue Cross and Blue Sheld

SilverHSA eligible

Ind. deductible: $4,000
Family deductible: $4,000
Ind. OOP max: $7,250
Family OOP max: $7,250

Other cost-sharing reduction variants for this plan:

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$562	—
30	$638	—
40	$718	—
50	$1,004	—
60	$1,526	—

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	$40.00 Copay after deductible

Specialist

Benefit	In-network
Specialist Visit	$60.00 Copay after deductible

Hospital

Benefit	In-network
Emergency Room Services	$350.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	10.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	10.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$100.00 Copay after deductible

Pharmacy

Benefit	In-network
Generic Drugs	$25.00 Copay after deductible
Non-Preferred Brand Drugs	30.00% Coinsurance after deductible
Preferred Brand Drugs	$80.00 Copay after deductible
Specialty Drugs	40.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	10.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$25.00 Copay after deductible

Other

Benefit	In-network
Chemotherapy	10.00% Coinsurance after deductible
Abortion for Which Public Funding is Prohibited	10.00% Coinsurance after deductible
Accidental Dental	10.00% Coinsurance after deductible
Acupuncture	$40.00 Copay after deductible
Allergy Testing	10.00% Coinsurance after deductible
Bariatric Surgery	10.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	40.00% Coinsurance after deductible
Chiropractic Care	$40.00 Copay after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	10.00% Coinsurance after deductible
Dental Check-Up for Children	No Charge after deductible
Diabetes Education	$60.00 Copay after deductible
Dialysis	10.00% Coinsurance after deductible
Durable Medical Equipment	10.00% Coinsurance after deductible
Emergency Transportation/Ambulance	10.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$40.00 Copay after deductible
Hearing Aids	10.00% Coinsurance after deductible
Home Health Care Services	10.00% Coinsurance after deductible
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	10.00% Coinsurance after deductible
Infertility Treatment	10.00% Coinsurance after deductible
Infusion Therapy	10.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	10.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	No Charge after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	50.00% Coinsurance after deductible
Nutritional Counseling	$25.00 Copay after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	$40.00 Copay after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	10.00% Coinsurance after deductible
Outpatient Rehabilitation Services	$40.00 Copay after deductible
Prenatal and Postnatal Care	10.00% Coinsurance after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	10.00% Coinsurance after deductible
Radiation	10.00% Coinsurance after deductible
Reconstructive Surgery	10.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$40.00 Copay after deductible
Rehabilitative Speech Therapy	$40.00 Copay after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	$20.00
Routine Eye Exam for Children	No charge
Routine Foot Care	$60.00 Copay after deductible
Skilled Nursing Facility	10.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	10.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$25.00 Copay after deductible
Transplant	10.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	10.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	10.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.