Plan Benefits |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
 |
Annual Deductible Choices
(Not combined for In-Network & Out-of-Network) |
Individual: $500 / $1,500 / $2,500 / $5,000 /$7,500
Family : $1,000 / $3,000 / $5,000 / $10,000 |
Individual: $5,000 / $5,000 / $5,000 / $5,000 /$7,500
Family : $10,000 / $10,000 / $10,000 / $15,000 |
| Each family member has an individual deductible. The family deductible can be satisfied by 2 or more members |
Annual Out-of-Pocket Maximum
(Includes deductible)
|
Individual: $3,000 / $4,000 / $5,000 / $7,500 / $10,000 |
$15,000 / $15,000 / $15,000 / $15,000 / $17,500 |
| Family: $6,000 / $8,000 / $10,000 / $15,000 / $20,000 |
$30,000 / $30,000 / $30,000 / $30,000 / $35,000 |
Lifetime Maximum
(Combined for In-Network & Out-of-Network) |
Plan pays up to $7 Million per member |
Covered Services |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
| Doctors' Office Visits |
$30 copay for first 3 visits per member per year (deductible waived); after three visits and once deductible is met, then 30% of negotiated fee |
50% of negotiated fee plus all excess charges |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
30% of negotiated fee |
50% of negotiated fee plus excess charges |
Hospital Inpatient
(Overnight Hospital Stays) |
30% of negotiated fee |
All Charges except $650 per day |
Hospital Inpatient
(If You Don't Stay Overnight) |
30% of negotiated fee |
All Charges except $380 per day |
| Emergency Room Services |
30% of negotiated fee |
50% of customary and reasonable fees plus all excess charges |
| Maternity |
Not Covered |
Not Covered |
Preventive Care Services
(including appropriate screening for breast, cervical, ovarian, and prostate cancer)
|
Annual physical exam(s): 30% of negotiated fee
Routine mammogram, Pap and PSA tests: 30% of negotiated fee (deductible waived)
Well Baby and Well Child (through age 6): 30% of negotiated fee |
Annual physical exam(s): 50% of negotiated fee plus all excess charges
Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges
Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges |
| Ambulance |
20% of negotiated fee |
50% of negotiated fee plus all charges in excess of negotiated fee and in excess of the plan's $75 maximum payment per ground trip |
| Physical & Occupational Therapy; Chiropractic Services |
30% of negotiated fee. Plan pays up to a total of 24 visits per year |
50% of negotiated fee. Plan pays up to a total of 24 visits per year |
Prescription Drug Coverage |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
Generic Prescription Drug Plan
(Drugs on Generic Rx Formulary only) |
Generic Coverage Only
$15 copay (or 40%, whichever is greater) |
NOT COVERED
|
Comprehensive Prescription Drug Plan
(Blue Cross Formulary Drugs) |
Generic: $15 Copay (or 40%, whichever is greater)
$500 annual brand-name/specialty drug deductible (2 member maximum) applies before the following:
Brand-name: $15 copay (or 40%, whichever is greater not to exceed $500 per prescription)
Specialty: 40% - $5,000 annual out-of-pocket maximum (the most you will have to pay) (In-network only and in addition to brand-name/specialty drug deductible) |
Consider Other Anthem Blue Cross Blue Shield of Colorado PPO Plans |
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Anthem California
