Benefit |
In-Network |
Out-of-Network |
 |
| Annual Deductible |
This plan features two separate medical deductibles: $500 per member for emergency and hospital inpatient/outpatient services; and $5,000 per member for other covered services
(Once 2 members each reach the deductibles, deductibles are satisfied for the entire family) |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(includes deductible)
Participating & non-participating provider covered services apply
|
Both medical deductibles apply ot satisfy a total of $5,000 per member
(Once 2 members each reach the maximum, the maximum is satisfired for the entire family) |
Doctors' Office Visits
Number of office visits is combined for participating and non-participating providers |
Chidren: 4 office visits per year at $30 copay per visit; Adults: 2 office visits per year at $30 copay per visit (deductible waived) |
Chidren: 4 office visits per year; Adults: 2 office visits per year; 50% of negotiated fee plus all excess charges (deductible waived) |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
20% of negotiated fee for inpatient or surgical procedures only. You pay for other covered services until the out-of-pocket maximum is met, then plan pays 100% of negotiated fee. |
50% of negotiated fee plus all excess charges for inpatient or surgical procedures only. You pay for other covered services until out-of-pocket maximum is met. |
Hospital Inpatient
(Overnight Hospital Stays) |
20% of negotiated fee2 |
All Charges except $650 per day |
Hospital Outpatient
(If You Don't Stay Overnight) |
20% of negotiated fee2 |
All Charges except $380 per day |
| Emergency Room Services |
20% of negotiated fee |
20% of customary and reasonable fees plus all excess charges |
| Maternity |
Not Covered |
Not Covered |
| Preventive Care |
HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived)
Routine mmamogram, Pap and PSA tests4: 20% of negotiated fee (deductible waived) |
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) |
| Ambulance |
20% of negotiated fee |
50% of negotiated fee plus all charges in excessof negotiated fee and in excess of the plan's $75 maximum payment per ground trip |
| Physical & Occupational Therapy; Chiropractic Services |
20% of negotiated fee up to 12 visits per year |
All charges except $25 per visit, up to 12 visits per year |
| Accupunture/Accupressure |
All charges except $25 per visit, up to 24 visits per year |
All charges except $25 per visit, up to 24 visits per year |
Prescription Drugs
Amounts shown are for each 30 day retail or in-network mail order supply |
$10 copay generic; $30 brand-name after $500 brand-name prescription drug deductible (2 member maximum); 30% of negotiated fee for sell administered injectables, except insulin |
50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benefits; subject to the annual $500 brand-name prescription drug deductible |
Consider Other Anthem Blue Cross PPO Plan Links |
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Anthem California
