Plan Benefits |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
| Annual Deductible |
0 |
0 |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(Combined for In-Network and Out-of-Network) |
7,500 |
7,500 |
Doctors' Office Visits
|
$40 Copay |
50% of negotiated fee plus all excess charges |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
40% of negotiated fee |
50% of negotiated fee plus all excess charges |
Hospital Inpatient
(Overnight Hospital Stays) |
40% of negotiated fee plus $500 copay per day/4-day maximum copay per admission |
All Charges except $650 per day |
Hospital Outpatient
(If You Don't Stay Overnight) |
40% of negotiated fee plus $500 copay per surgical admission |
All Charges except $380 per day |
| Emergency Room Services |
40% of negotiated fee |
40% of customary and reasonable fees
plus all excess charges |
| Maternity |
Not Covered |
Not Covered |
| Preventive Care |
Routine mammogram, Pap and PSA tests $40 office visit plus 40% of negotiated fee
Well Baby and Well Child (trough age 6): $40 office visit plus 40% of negotiated fee
HealthyChecksm Centers: $25/$75 copay for basic/premium screening |
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges
Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges |
| Ambulance |
40% of negotiated fee |
50% of negotiated fee plus all charges |
| Physical/Occupational Therapy; Chiropractic Services |
40% of negotiated fee, up to 12 visits per year |
All charges except $25 per visit, up to 12 visits per year |
Accupunture/Accupressure
(Combined for In-Network and Out-of-Network) |
All charges except $25 per visit, 24 visits per year |
All charges except $25 per visit, 24 visits per year |
| Prescription Drugs |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
| RightPlan PPO 40 with No Prescription Drug Coverage (P958) |
No Prescription Drug Coverage |
No Prescription Drug Coverage |
RightPlan PPO 40 with Generic Prescription Drug Coverage (PE48)
(30-day supply, retail & mail order) |
$10 copay generic
(Drugs on Genreic Rx Formulary only) |
50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits
(Drugs on Generic Rx Formulary only) |
RightPlan PPO 40 with Comprehensive Prescription Drug Coverage (PE49)
(30-day supply, retail & mail order) |
Blue Cross Formulary Drugs
$10 copay generic; $20 copay brand-name after annual $500 brand-name prescription drug deductible; 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 benefits; subject to the annual $500 brand-name prescription drug deductible |
| Consider Other Anthem Blue Cross - California PPO Plan Links |
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Aetna
