Calendar Year Deductible |
Your Choices - Only Inpatient Services, Outpatient Surgery and Emergency Room Services Apply. Toward the Deductibles Below
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| Individual (In-network & Out-of-Network) |
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Family (In-network & Out-of-Network)
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| In-Network Coinsurance |
40% |
Out-of-Pocket Maximum |
Add Your Chosen Deductible to the Amount Below
All covered medical services apply toward the out-of-pocket maximums below |
| Individual |
In-network |
Out-of-Network |
|
$3,500 |
$3,500 |
$3,500 |
Both network and non-network services accumulate toward these out-of-poket maximums |
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| Family |
In-network |
Out-of-Network |
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$1,000 |
$3,300 |
$5,000 |
Both network and non-network services accumulate toward these out-of-poket maximums |
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| How family deductibles and family out-of-pocket maximums work |
Once one family member reaches their individual deductible or out-of-pocket maximum, the remaining amount of the family deductible or out-of-pocket maximum needs to be met by one or more other family members. The family deductible or out-of-pocket maximum can be met by the family combined. |
| Plan Lifetime Maximum |
Plan pays up to $4 million per member for in-network and out-of-network services combined. |
| Covered Services |
Your Share of Costs (after deductible, if applicable) |
| Doctor's Office Visits |
In-Network |
$40 copay for first 2 office visits (immediate coverage); then 0% Coinsurance after out-of-pocket is met |
| Out-of-Network |
100% Coinsurance; then 50% Coinsurance after out-of-pocket is met |
Professional/Diagnostic Services
(X-ray, lab, anesthesia, surgeon, etc.) |
In-Network |
Inpatient: 40% Coinsurance
Outpatient: 100% of negotiated fee; then 0% Coinsurance after out-of-pocket is met |
| Out-of-Network |
Inpatient: 50% Coinsurance
Outpatient: 100% Coinsurance; then 50% after out-of-pocket maximum is met |
Inpatient Services
(overnight hospital/facility stays) |
In-Network |
40% Coinsurance |
| Out-of-Network |
All charges except $650 per day |
Outpatient Services
(without overnight hospital/facility stays) |
In-Network |
Surgery: 40% Coinsurance
Other Services: 100% of negotiated fee; then 0% Coinsurance after out-o-pocket maximum is met |
| Out-of-Network |
All charges except $650 per day
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| Emergency Room Services |
In-Network or Out-of-Network:
40% Coinsurance plus $100 Emergency Room copay (copay waived if admitted) |
| Preventive Care Services |
In-Network |
HealthCheck Centers (immediate coverage): $25 Basic/$75 Premium (for ages 7 & older). For Members covered more than 6 months (deductible does not apply): Routine mammogram, Pap and PSA tests: 40% Coinsurance. childhood immunizations through age 6: 40% Coinsurance |
| Out-of-Network |
For members covered more than 6 months (deductible does not apply): Routine mammogram, Pap and PSA tests: 50% Coinsurance. Childhood immunizations through age 6: 50% Coinsurance. |
| Maternity |
Not Covered |
| Optional Coverage (additional cost) |
Dental, Life |
| Prescription Drug Coverage |
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| Retail Drugs (and Mail Order Drugs when available) |
In-Network |
Tier 1 (Lower cost Generic & Brand-name drugs): $15 Copay
$2,000 annual deductible per member applied before the following:
- Tier 2 (HIgher cost Generic & Brand-name drugs): $35 Copay
- Specialty: 25% Coinsurance up to a $2,500 Annual Out-of-Pocket Maximum (the most you'll have to pay), in-network only and in addition to $2,000 annual deductible
Non-formulary drugs: Not covered, discounts apply |
| Out-of-Network |
Not Covered |
| Other Covered Benefits include but are not limited to: |
Ambulance, Home Health Care, Physical/Occupational Therapy, Urgent Care |
Consider Other Anthem Blue Cross PPO Plan Links |
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Some of Anthem's lowest monthly rates plus 2-year rate guarantees with $3,300 and $5,000 deductible plans.
Aetna
