|
Monthly
Premium: |
|
Plan
Type: |
|
PPO
|
PPO |
Physician
Choice: |
|
You
choose specialist(s) |
You
choose specialist(s) |
Annual
Deductible: |
|
$3,300
single/$6,600 family |
$1,000
single/$2,000 family |
Annual
Out-of-Pocket Maximum
(in addition to deductible): |
|
$3,500
single/$7,000 family |
$3,500
single/$7,000 family |
Office
Visits: |
|
$40
copay for first 2
visits per member
per year, deductible
waived |
$40
copay for first 2
visits per member
per year, deductible
waived |
Professional
Services: |
|
Outpatient:
100% of negotiated
fee, then 0% after
Out-of-Pocket Limit
is met. Inpatient:
40% of negotiated
fee. |
Outpatient:
100% of negotiated
fee, then 0% after
Out-of-Pocket Limit
is met. Inpatient:
40% of negotiated
fee. |
Hospital
Inpatient/Outpatient: |
|
Outpatient:
100% of negotiated
fee, then 0% after
Out-of-Pocket Limit
is met. Inpatient:
40% of negotiated
fee. |
Outpatient:
100% of negotiated
fee, then 0% after
Out-of-Pocket Limit
is met. Inpatient:
40% of negotiated
fee. |
Emergency
Services: |
|
40%
of negotiated fee;
$100 ER copay, waived
if admitted |
40%
of negotiated fee;
$100 ER copay, waived
if admitted |
Maternity: |
|
Not
covered |
Not
covered |
Preventive
Care - General: |
|
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
Drug
Benefits: |
|
Tier
1: $15 copay; Tier
2, Tier 3 and Specialty:
100% of negotiated
fee until $7500 deductible
is met. After $7500
deductible is met:
Tier 2 - $40 copay;
Tier 3 - $60 copay;
Specialty - 25% up
to $2500 annual out-of-pocket
maximum |
Tier
1: $15 copay; Tier
2, Tier 3 and Specialty:
100% of negotiated
fee until $7500 deductible
is met. After $7500
deductible is met:
Tier 2 - $40 copay;
Tier 3 - $60 copay;
Specialty - 25% up
to $2500 annual out-of-pocket
maximum. |
Financial/Tax
Incentive: |
|
No |
No |
Optometrist
Benefit: |
|
Optometrists
network has been created
for Anthem Blue Cross
Life and Health Insurance
Company so insureds
will have a participating
provider network to
choose from for medical
services. |
Optometrists
network has been created
for Anthem Blue Cross
Life and Health Insurance
Company so insureds
will have a participating
provider network to
choose from for medical
services. |
Preservice
Review: |
|
Preservice
review will be required
for all inpatient
hospital stays and
certain diagnostic
and radiological procedures. |
Preservice
review will be required
for all inpatient
hospital stays and
certain diagnostic
and radiological procedures. |
Specialty
Pharmacy Drug Benefit: |
|
Certain
drugs will be obtainable
only through Anthem's
Specialty Preferred
Provider. |
Certain
drugs will be obtainable
only through Anthem's
Specialty Preferred
Provider. |
Annual
Physical Exam: |
|
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
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