| Monthly
Premium: |
|
| Plan
Type: |
PPO |
PPO |
PPO |
PPO
|
PPO |
| Physician
Choice: |
You
choose specialist(s)
|
You
choose specialist(s)
|
You
choose specialist(s)
|
You
choose specialist(s)
|
You
choose specialist(s)
|
| Annual
Deductible: |
$5,000
single/$10,000 family
maximum
.........................
$6,000 single/$12,000
family maximum |
>
$3,500
single/$7,000 family
maximum |
$2,500
single/$5,000 family
maximum |
$1,500
single/$3,000 family
maximum |
$1,000
single/$2,000 family
maximum |
| Annual
Out-of-Pocket Maximum
(in addition to deductible): |
$4,500
single/$9,000 family
maximum |
$4,500
single/$9,000 family
maximum |
$4,500
single/$9,000 family
maximum |
$4,500
single/$9,000 family
maximum |
$4,500
single/$9,000 family
maximum |
| Office
Visits: |
Deductible
waived: $30 copay for
non-specialist; $50
copay for specialist.
|
Deductible
waived: $30 copay for
non-specialist; $50
copay for specialist.
|
Deductible
waived: $30 copay for
non-specialist; $50
copay for specialist.
|
Deductible
waived: $30 copay for
non-specialist; $50
copay for specialist.
|
Deductible
waived: $30 copay for
non-specialist; $50
copay for specialist.
|
| Professional
Services: |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
| Hospital
Inpatient/Outpatient: |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
| Emergency
Services: |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
25%
of negotiated fee |
| Maternity: |
Not
Covered |
Not
Covered |
Not
Covered |
Not
Covered |
Not
Covered |
| Preventive
Care - General: |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
| Dental: |
Not
Available |
Not
Available |
Not
Available |
Not
Available |
Not
Available |
| Drug
Benefits: |
Tier
1: $15 copay; Tier 2,
Tier 3 and Specialty:
100% of negotiated fee
until $500 deductible
is met. After $500 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 $500 deductible
is met. After $500 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 $500 deductible
is met. After $500 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 $500 deductible
is met. After $500 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 $500 deductible
is met. After $500 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
|
No
|
No
|
No
|
| Optometrist
Benefit: |
Annual
Routine Vision Exam:
$20 copay. |
Annual
Routine Vision Exam:
$20 copay. |
Annual
Routine Vision Exam:
$20 copay. |
Annual
Routine Vision Exam:
$20 copay. |
Annual
Routine Vision Exam:
$20 copay. |
| 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.
|
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.
|
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 |
Certain
drugs will be obtainable
only through Anthem's
Specialty Preferred
Provider |
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 |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
You
pay 0%, not subject
to deductible |
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