Plan Benefits |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
 |
Annual Deductible Choices
(Not combined for In-Network & Out-of-Network) |
Individual: $500 / $1,500 / $2,500 / $5,000
Family : $1,000 / $3,000 / $5,000 / $10,000 |
Individual: $5,000
Family : $10,000 |
| Each family member has an individual deductible. The family deductible can be satisfied by 2 or more members |
Annual Out-of-Pocket Maximum
(Includes deductible)
|
Individual: $2,500 |
$10,000 |
| Family: $5,000 aggregate* |
$20,000 aggregate* |
Lifetime Maximum
(Combined for In-Network & Out-of-Network) |
Plan pays up to $7 Million per member |
Covered Services
The amounts shown are your share of costs after any deductible |
In-Network
(Coinsurance amounts are
percentage
of negotiated fee) |
Out-of-Network
(Coinsurance amounts are percentage
of negotiated fee, plus any amounts
charged over that fee) |
| Doctors' Office Visits |
$30 copay for first 3 visits per member per year (deductible waived); after three visits and once deductible is met, then 30% of negotiated fee |
50% of negotiated fee plus all excess charges |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
30% of negotiated fee |
50% of negotiated fee plus excess charges |
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 |
50% of customary and reasonable fees plus all excess charges |
| Maternity |
Not Covered |
Not Covered |
Preventive Care Services
(including appropriate screening for breast, cervical, ovarian, and prostate cancer) |
Annual physical exam(s): 30% of negotiated fee
Routine mammogram, Pap and PSA tests: 30% of negotiated fee (deductible waived)
Well Baby and Well Child (through age 6): 30% of negotiated fee |
Annual physical exam(s): 50% of negotiated fee plus all excess charges
Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges
Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges |
| Physical & Occupational Therapy; Chiropractic Services |
30% of negotiated fee. Plan pays up to a total of 24 visits per year |
50% of negotiated fee. Plan pays up to a total of 24 visits per year |
Prescription Drug Coverage |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
Generic Prescription Drug Plan
(Drugs on Generic Rx Formulary only) |
Generic Coverage Only
$15 copay (or 40%, whichever is greater) |
Generic Coverage Only
$15 copay (or 40%, whichever is greater) plus any difference between the actual charges and Anthem's allowed amount |
Comprehensive Prescription Drug Plan
(Blue Cross Formulary Drugs) |
Generic: $15 Copay (or 40%, whichever is greater) |
$15 copay (or 40% whichever is greater) plus any difference between the actual charges and Anthem's allowed amount |
$500 annual brand-name/specialty drug deductible (2 member maximum) applies before the following:
Brand-name: $15 copay (or 40%, whichever is greater not to exceed $500 per prescription)
Specialty: 40% - $5,000 annual out-of-pocket maximum (the most you will have to pay) (In-network only and in addition to brand-name/specialty drug deductible) |
$500 separate annual deductible, then $15 copay (or 40% whichever is greater) plus the difference in the cost between the brand name drug and the generic equivalent, if available.
You are also responsible for any difference between the pharmacy cash price and Anthem's allowed amount |
Consider Other Anthem Blue Cross PPO Plan Links |
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Anthem California
