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Anthem Blue Cross CoreGuard PPO
Benefit Guide for California |
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|
Calendar Year Deductible |
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|
Individual (In-network & Out-of-Network) |
$750 |
$1,500 |
$2,500 |
$3,500 |
$5,000 |
$7,500 |
$10,000 |
|
Family (In-network & Out-of-Network) |
$1,550 |
$3,000 |
$2,500 |
$3,500 |
$5,000 |
$7,500 |
$10,000 |
|
| In-Network Coinsurance |
50% |
Out-of-Pocket Maximum |
Add Your Chosen Deductible to the Amount Below |
| Individual |
In-network |
Out-of-Network |
|
$3,500 |
$3,500 |
$3,500 |
$3,500 |
$3,500 |
$3,500 |
$0 |
$7,500 |
$7,500 |
$7,500 |
$7,500 |
$7,500 |
$7,500 |
$7,500 |
|
| Family |
In-network |
Out-of-Network |
|
$7,000 |
$7,000 |
$7,000 |
$7,000 |
$7,000 |
$7,000 |
$0 |
$15,000 |
$15,000 |
$15,000 |
$15,000 |
$15,000 |
$15,000 |
$15,000 |
|
| How family deductibles and family out-of-pocket maximums work |
Each family member has an individual deductible and out-of-pocket maximum. 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. |
| 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, unless waived) |
| Doctor's Office Visits |
In-Network |
50% Coinsurance (with $750, $1,500, $2,500, $3,500, $5,000, $7,500)
0% Coinsurance (with $10,000) |
| Out-of-Network |
70% Coinsurance (with $750, $1,500, $2,500, $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
Professional/Diagnostic Services
(X-ray, lab, anesthesia, surgeon, etc.) |
In-Network |
50% Coinsurance (with $750, $1,500, $2,500, $3,500, $5,000, $7,500)
0% Coinsurance (with $10,000) |
| Out-of-Network |
70% Coinsurance (with $750, $1,500, $2,500, $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
Inpatient Services
(overnight hospital/facility stays) |
In-Network |
50% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
50% Coinsurance (with $3,500, $5,000, $7,500)
0% Coinsurance (with $10,000) |
| Out-of-Network |
70% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
70% Coinsurance (with $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
Outpatient Services
(without overnight hospital/facility stays) |
In-Network |
50% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
50% Coinsurance (with $3,500, $5,000, $7,500)
0% Coinsurance (with $10,000) |
| Out-of-Network |
70% Coinsurance PLUS $500 Facility Copay per day up to the first 3 days (with $750, $1,500, $2,500)
70% Coinsurance (with $3,500, $5,000, $7,500)
30% Coinsurance (with $10,000) |
| Emergency Room Services |
In-Network or Out-of-Network:
50% Coinsurance (with $750, $1500, $2500, $3500, $5000, $7500) or 0% Coinsurance (with $10000) |
| Preventive Care Services |
In-Network |
Adults and children ages 7-17: Routine Mammogram, PAP and PSA tests: 50% Coinsurance (or 0% Coinsurance with $10,000 plan)
HealthCheck Centers: $25 Basic/ $75 Premium, deductible waived |
| Out-of-Network |
Adults and children ages 7-17: Routine Mammogram, PAP and PSA tests: 70% Coinsurance (or 30% Coinsurance with $10,000 plan) |
| Maternity |
Not Covered |
| Additional Covered Benefits |
Includes but not limited to: Ambulance, Chiropractic Services, Home Health Care, Mental Health,
Physical / Occupational Therapy, Urgent Care |
| Prescription Drug Coverage |
|
| Retail and Mail Order Drugs on the Plan Formulary |
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 |
Consider Other Anthem Blue Cross PPO Plan Links |
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