|
| Benefit |
In-Network |
Out-of-Network |
 |
| Annual Deductible |
$5,000 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 per member |
Annual Out-of-Pocket Maximum
(includes deductible)
Participating & non-participating provider covered services apply
|
$7,500 per member, only hospital costs apply
(Once 2 members each reach the deductible, the deductible is satisfied for the entire family) |
| Doctors' Office Visits |
No office visit benefit until out-of-pocket maximum is met, then you pay $0 of negotiated fee |
No office visit benefit until out-of-pocket maximum is met, then you pay 50% of negotiated fee plus all excess charges |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
30% of negotiated fee for inpatient or surgical procedures only. No office visit benefits until out-of-pocket maximum is met, then you pay $0 of negotiated fee |
50% of negotiated
fee plus excess charges for covered inpatient or surgical procedures only |
Hospital Inpatient
(Overnight Hospital Stays) |
30% of negotiated fee |
All Charges except $650 per day |
Hospital Outpatient
(If You Don't Stay Overnight) |
30% of negotiated fee |
All Charges except $380 per day |
| Emergency Room Services |
30% of negotiated fee |
30% of customary and reasonable fees plus all excess charges |
| Maternity |
Not covered |
Not covered |
| Preventive Care |
Routine mammogram, Pap and PSA tests:
30% of negotiated fee (deductible waived)
HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived) |
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) |
| Ambulance |
30% of negotiated fee |
50% of negotiated fee plus all charges in excess of the plan's $750 maximum payment per ground trip |
| Physical & Occupational Therapy; Chiropractic Services |
Not covered unless during inpatient admission |
Not covered unless during inpatient admission |
| Accupunture/Accupressure |
Not Covered |
Generic Prescription Drugs
(no deductible) |
$10 copay generic (Drugs on Generic Rx Formulary Only) |
$10 copay generic (Drugs on Generic Rx Formulary Only) |
Consider Other Anthem Blue Cross PPO Plan Links |
|
|
|
|
|
 |
|