| Annual deductible |
In-Network
| $2,000 employee only contract or $4,000 family contract (employee plus one or more dependents) - aggregate |
Out-Of-Network
| Not applicable |
| Lifetime covered charges paid by Anthem blue cross |
In-Network
| $5,000,000 |
Out-Of-Network
| Not applicable |
Annual out-of-pocket maximum
Certain member payments do not apply |
In-Network
| $3,100 employee contract or $5,700 family contract (employee plus one or more dependents) - aggregate |
Out-Of-Network
| Not applicable |
| Office visits |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
| Other professional services, including maternity, diagnostic lab and x-ray |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Hospital inpatient facility services
Preservice Review required |
In-Network
| PREFERRED PARTICIPATING HOSPITALS AND PARTICIPATING HOSPITALS: 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered, except in emergencies after deductible |
| Hospital inpatient professional services (lab, physician, anesthesia) |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered, except in emergencies after deductible |
Hospital outpatient services
Preservice Review required for certain surgical services and diagnostic procedures |
In-Network
| PREFERRED PARTICIPATING HOSPITALS AND PARTICIPATING HOSPITALS: 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered, except in emergencies after deductible |
Ambulatory Surgical Centers
Preservice Review required |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Prescription Drugs
30-day supply retail; Up to a 60-day supply available through mail order |
In-Network
| $10 copay generic (for each 30-day supply), $25 copay brand (for each 30-day supply) after annual deductible; self-administered injectable drugs, except Insulin, 30% of the negotiated fee after annual deductible; infertility drug lifetime maximum benefit $1,500 |
Out-Of-Network
| Not covered |
HealthyCheck screenings, Ages 7-adult
Includes certain lab tests, immunizations and health education information |
In-Network
| $25 or $75 copay health screening options.
Not subject to annual deductible |
Out-Of-Network
| Not Available |
| Well-baby immunizations and adult screening tests |
In-Network
| 20% of negotiated fee after annual deductible
CHILDREN THROUGH AGE 6: regular check-up and immunizations
AGES 7-ADULT: limited to annual pap, breast exam, and mammogram for women and Prostate Specific Antigen (PSA) study for men. |
Out-Of-Network
| Not covered |
| Emergency Care |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| 20% of customary and reasonable charges plus 100% of charges in excess of customary and reasonable after deductible |
| Ambulance |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| 20% of customary and reasonable charges plus 100% of charges in excess of customary and reasonable after deductible |
Skilled Nursing Facility
100 days per year; Preservice Review required |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Home Health Care
90 four-hour visits per year; Preservice Review required |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Physical/Occupational Therapy, Chiropractic Care
Total of 12 visits a year |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Acupuncture/Acupressure
Total of 12 visits per year |
In-Network
| All of the negotiated fee except $25 per visit after annual deductible |
Out-Of-Network
| Not covered |
Mental Health*, including Chemical Dependency Inpatient:
Anthem blue cross pays $5,250 maximum benefit per year |
In-Network
| All of the negotiated fee except $175 per day after annual deductible |
Out-Of-Network
| Not covered |
Mental Health*, including Chemical Dependency Outpatient professional services:
One visit per day; 20 visits per year |
In-Network
| All of the negotiated fee except $25 per visit after annual deductible |
Out-Of-Network
| Not covered |
Infusion Therapy, including Chemotherapy
Preservice Review required |
In-Network
| 20% of negotiated fee after annual deductible |
Out-Of-Network
| Not covered |
Infertility
Lifetime maximum $2000 for hospital and professional services combined |
In-Network
| 20% of negotiated fee after additional $500 copay; subject to annual deductible |
Out-Of-Network
| Not covered |
