| Benefit |
HMO Saver In-Network |
Individual HMO Out-of-Network |
 |
| Annual Deductible |
$1,500 per member: Inpatient/Outpatient Hospital Services and Ambulatory Surgical Centers |
$0 |
| Lifetime Maximum |
Unlimited |
| Annual Out-of-Pocket Maximum |
$3,000 per member: Once two members each reach the maximum, the maximum is satisfied for the entire family (includes deductible) |
$3,000 per member: Once two members each reach the maximum, the maximum is satisfied for the entire family |
| Doctors' Office Visits |
$10 copay per visit |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
No Charge for office visit-related services |
No Charge for office visit-related services |
Hospital Inpatient
(Overnight Hospital Stays) |
20% of negotiated fee (after deductible) |
20% of negotiated fee |
Hospital Outpatient
(If You Don't Stay Overnight) |
20% of negotiated fee (emergency and non-emergency services are subject to the deductible) |
20% of negotiated fee |
| Emergency Room Services |
20% of negotiated fee (after deductible) |
20% of negotiated fee |
| Maternity |
Office visits:$10 copay Inpatient/Outpatient: After deductible, 20% of negotiated fee |
Office visits:$10 copay Inpatient/Outpatient: 20% of negotiated fee |
| Preventive Care |
$10 Copay for specific health maintenance services |
$10 Copay for specific health maintenance services |
| Ambulance |
$50 Copay waived if admitted to hospital |
$50 Copay waived if admitted to hospital |
Physical & Occupational Therapy; Chiropractic Services
(up to 60 consecutive days following an illness or injury) |
Outpatient: $10 Copay per visit
Inpatient: 20% of negotiated fee
Chiropractic services provided with medical group referral only |
| Accupunture/Accupressure |
Not Covered |
Prescription Drugs
(Blue Cross Formulary)
Amounts shown are for each 30-day retail or in-network mail order supply |
$10 copay generic; $30 copay brand-name after $250 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self administered injectables, except insulin |
50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benfits; subject to the annual $500 brand-name prescription drug deductible. |
| Other Anthem Blue Cross PPO Plan Links |
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Anthem California
