Benefit |
In-Network |
Out-of-Network |
 |
| Annual Deductible |
$3,500 per member
(Once 2 members each reach the deductible, the deductible is satisfied for the entire family) |
| Lifetime Maximum |
$5,000,000 per member |
Annual Out-of-Pocket Maximum
(includes deductible)
Participating & non-participating provider covered services apply
|
This is satisfied once the
annual deductible is met |
$10,000 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family) |
| Doctors' Office Visits |
$0 after deductible |
50% of negotiated fee plus all excess charges (after deductible ) |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
$0 after deductible |
50% of negotiated
fee plus excess charges (after deductible) |
Hospital Inpatient
(Overnight Hospital Stays) |
$0 after deductible |
All Charges except $650 per day |
Hospital Outpatient
(If You Don't Stay Overnight) |
$0 after deductible |
All Charges except $380 per day |
| Emergency Room Services |
$0 after deductible |
All charges in excess of customary and reasonable fees (after deductible) |
| Maternity |
Not covered |
Not covered |
| Preventive Care |
Routine mammogram, Pap and PSA tests4: $0 after deductible
HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived)
Well Baby and Well Child (through age 6): $0 after deductible |
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (after deductible)
Well Baby and Well Child (through age 6): 50% of negotieated fee plus all excess charges (after deductible) |
| Ambulance |
$0 after deductible |
50% of negotiated fee plus excess charges (after deductible) |
| Physical & Occupational Therapy; Chiropractic Services |
$0 after deductible |
All charges except $25 per visit, (after deductible) |
| Accupunture/Accupressure |
All Charges except $25 per visit, up to 24 visits per year (after deductible) |
Prescription Drugs
(Blue Cross Formulary7)
Amounts shown are for each 30-day retail or in-network mail order supply |
$10 copay genric; $30 copay brand-name8 (after $500 brand name prescription drug deductible), 30% of negotiated fee for self administered injectables, except insulin (after annual deductible) |
50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benfits (after deductible) |
Consider Other Anthem Blue Cross PPO Plan Links |
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Anthem California
