Benefit |
In-Network |
Out-of-Network |
 |
| Annual Deductible |
$1,000/$2,500 Per member, inpatient or surgical procedures only
(Once 2 members each reach the deductible,
the deductible
is satisfied for the entire family.) |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(includes deductible)
(Combined for In-Network & Out-of-Network)
|
$3,500/$5,000 per member, only hospital costs apply
(Once 2 members each reach the maximum, the maximum is satisfied for the entire family) |
| Doctors' Office Visits |
No office visit benefit until out-of-pocket maximum is met, then plan pays 100% of negotiated fee |
No office visit benefit until out-of-pocket maximum is met, then plan pays 50% of negotiated fee plus all excess charges |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
20% of negotiated fee for inpatient or surgical procedures only. No office visit benefits until out-of-pocket maximum is met, then plan pays 100% of negotiated fee |
50% of negotiated fee plus excess charges for covered inpatient or surgical procedures only |
Hospital Inpatient
(Overnight Hospital Stays) |
20% of negotiated fee2 |
All Charges except $650 per day |
Hospital Inpatient
(If You Don't Stay Overnight) |
20% of negotiated fee2 |
All Charges except $380 per day |
| Emergency Room Services |
20% of negotiated fee |
20% of customary and reasonable fees plus all excess charges |
| Maternity |
Not Covered |
Not Covered |
| Preventive Care |
HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived) Routine mammogram, Pap and PSA tests4: 20% of negotiated fee (deductible waived) |
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) |
| 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 |
Not Covered unless during inpatient admission All charges except $25 per visit, up to 12 visits per year6 |
| Acupuncture/Acupressure |
Not Covered |
Not Covered |
| Prescription Drugs |
Not Covered |
Not Covered |
Consider Other Anthem Blue Cross PPO Plan Links |
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Anthem California
