| Annual medical deductible |
In-Network
| None |
Out-Of-Network
| None |
Lifetime covered charges
paid by Anthem blue cross |
In-Network
| Unlimited |
Out-Of-Network
| Not applicable |
| Annual out-of-pocket maximum |
In-Network
| $1,750 per member
$3,500 per family (two or moremembers-aggregate)
Certain member payments do not apply |
Out-Of-Network
| Not applicable |
Office visits,
including office visits for maternity |
In-Network
|
$10 co pay |
Out-Of-Network
| Not covered |
| Other professional services, including maternity, diagnostic lab and x-ray |
In-Network
| No charge |
Out-Of-Network
| Not covered |
| Hospital inpatient facility services |
In-Network
| No charge |
Out-Of-Network
| Not covered, except for certain emergency services |
| Hospital inpatient professional services (lab, physician, anesthesia) |
In-Network
| No charge |
Out-Of-Network
| Not covered, except for certain emergency services |
| Hospital outpatient services |
In-Network
| No charge |
Out-Of-Network
| Not covered, except for certain emergency services |
| Ambulatory Surgical Centers |
In-Network
| No charge |
Out-Of-Network
| Not covered, except for certain emergency services |
Prescription Drugs
30-day supply retail; Up to a 60-day supply available through mail order |
In-Network
|
$10 co pay generic (for each 30-day
supply) not subject to deductible, $20 co pay brand (for each
30-day supply) after annual $150 brand name prescription drug
deductible
per member, in-network and out-of-net-work combined, infertility drug lifetime maximum benefit $1,500 in-network and out-of-network combined, self-administered injectable drugs, except Insulin, 30% of the negotiated fee (subject to brand name prescription drug deductible if applicable)
If you select a brand-name drug when a generic equivalent drug
is available, even if the physician writes a "dispense as written"
or "do not substitute" prescription, the member will be responsible
for the generic co pay plus the difference in cost between the
brand-name and the generic equivalent drug. * |
Out-Of-Network
| 50% of Drug Limited Fee Schedule if filled within California after annual $150 brand name prescription drug deductible per member, in-network and out-of-network combined, infertility drug lifetime maximum benefit $1,500 in-network and out-of-net-work combined, Mail order not available |
| Well-baby immunization and adult screening tests |
In-Network
|
$10 co pay per office visit |
Out-Of-Network
| Not covered |
Emergency Care
$100 co pay for each visit - waived if admitted |
In-Network
| No charge |
Out-Of-Network
| No charge except 100% of amounts in excess of customary and reasonable fees |
| Ambulance |
In-Network
| No charge if ordered by the Primary Care Physician or in an emergency |
Out-Of-Network
| Not covered, except for certain emergency services |
Skilled Nursing Facility
100 days per year in a two-bed room |
In-Network
| No charge |
Out-Of-Network
| Not covered |
Home Health Care
Up to 3 two-hour visits per day |
In-Network
| No charge if ordered by the Primary Care Physician |
Out-Of-Network
| Not covered |
Physical/Occupational Therapy
Up to 60 consecutive days following an illness or injury |
In-Network
| No charge if ordered by the Primary Care Physician |
Out-Of-Network
| Not covered |
Chemical Dependency*
Inpatient: detoxification for alcohol or drug abuse (acute stage only) |
In-Network
| No charge |
Out-Of-Network
| Not covered |
Mental Health*
Outpatient professional services:
One visit per day, 20 visits per year |
In-Network
|
$20 co pay |
Out-Of-Network
| Not covered |
Infusion Therapy, including
Chemotherapy |
In-Network
| No charge |
Out-Of-Network
| Not covered |
| Infertility |
In-Network
| 50% charge |
Out-Of-Network
| Not covered |
HMO 100% (5038) 
