Blue Cross BlueShield of Illinois
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Anthem Blue Cross and Blue Shield - Blue Access Plan 3

Plan Feature In-Network You Pay Out-of-Network You Pay
Lifetime Maximum Benefit $7,000,000 per person
Deductible
Per individual, per calendar year.		 $2,500 individual / $5,000 family
$5,000 individual / $10,000 family
$10,000 individual / $20,000 family
 $5,000 individual / $10,000 family
$10,000 individual / $20,000 family
$20,000 individual / $40,000 family
Carryover Deductible Covered medical expenses incurred during the last 3 months of the calendar year, which are applied against the deductible but do not satisfy the calendar year deductible, may be carried over and applied against the deductible for the next calendar year. If the deductible is met, there is no carry-over.
Out-of-Pocket Expense Limit
Including deductible.		 $2,500 individual / $5,000 family
$5,000 individual / $10,000 family
$10,000 individual / $20,000 family
 $9,000 individual / $18,000 family
$14,000 individual / $28,000 family
$24,000 individual / $48,000 family
Physician Office Visits $01 50%1
Preventive Care $01 50%1
Well Child Care $01 50%1
Diagnostic Services $01 50%1
Inpatient Hospital $01 50%1
Outpatient Services $01 50%1
Emergency Room $01 50%1
Urgent Care $01 50%1
Ambulance $01 50%1
Maternity Services Not covered
Optional Maternity Rider
Subject to 12-month waitng period		 Not available
Outpatient Therapy Services
Maximum visits per benefit period for network and non-network combined:
  • Physical Therapy and Manipulation Therapy - 20 visits maximum
 $01 50%1
  • Speech Therapy - 20 visits maximum
 $01 50%1
  • Occupational Therapy - 20 visits maximum
 $01 50%1
Mental Health and Substance Abuse
  • Inpatient
 $01 50%1
  • Outpatient
 $01 50%1
  • Physican office services
 $01 50%1
Home Health Care
Maximum visits per benefit period - 60 visits		 $01 50%1
Hospice $01 50%1
Durable Medical Equipment
$4,000 maximum per benefit period		 $01 50%1
Prosthetic Devices
$4,000 maximum per benefit period		 $01 50%1
Human Organ and Tissue Transplant Services
Kidney and cornea transplant services covered same as any other illness under medical. Includes transportation, lodging, and meals.		 $01 50%1,2
Optional Anthem Blue Preferred Term Life Available as an option for additional cost
Anthem Dental Blue Option Available as an option for additional cost

Outpatient Prescription Drug Benefit In-Network You Pay Out-of-Network You Pay
Retail
30 day supply
  • Tier 1 Drugs3
 $15 co-payment2 50% - minimum $60 payment%
  • Tier 2 Drugs3
 $30 co-payment2 50% - minimum $60 payment%
  • Tier 3 Drugs3
 $60 co-payment2 50% - minimum $60 payment%
  • Tier 4 Drugs3
 $25% per prescription ($2,500 combined out-of-pocket maximum for retail and mail service) 50% - minimum $60 payment%
Mail Service
Up to a 90-day supply of maintenance drugs is available through mail service.
  • Tier 1 Drugs3
 $30 co-payment2 Not covered
  • Tier 2 Drugs3
 $75 co-payment2 Not covered
  • Tier 3 Drugs3
 $150 co-payment2 Not covered
  • Tier 4 Drugs3
 $25% per prescription ($2,500 combined out-of-pocket maximum for retail and mail service) Not covered

Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.
1Services subject to calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other.
2Co-payment does not apply to deductible or out-of-pocket maximums.
3Tier 1 Drugs - Nearly all Tier 1 drugs are Preferred Generic Prescription Drugs, but Tier 1 may also include some lower cost brand-name drugs with the greatest therapeutic value.

Tier 2 Drugs - Preferred Brand-Name and/or Generic Drugs that are lower-cost and provide greater therapeutic value than comparable brand-name drugs.

Tier 3 Drugs - Nearly all Tier 3 drugs are Brand-Name drugs that cost more or are less efficient than comparable drugs on lower tiers, but Tier 3 may also include some high-cost generic drugs.

Tier 4 Drugs - Generally includes self-injectable drugs. The list of Tier 4 Drugs can be found at anthem.com or by calling the number on the back of your ID card.
Blue Access PPO Network
These plans are available with the Blue Access PPO network. To find a doctor or local hospital, visit www.anthem.com and select the "Find a Doctor" button for a complete list of providers within the network.

Brief Outline of Coverage
This Anthem Blue Access Plan 3 Benefits Overview is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the contract or certificate of coverage. In the event of a conflict between the contract or certificate of coverage and this Anthem Blue Access Plan 3 Benefits Overview, the terms of the contract or certificate of coverage will prevail.

READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
 

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