Anthem Blue Cross and Blue Shield - Blue Access Value Plan
| 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. |
$2,000 individual / $4,000 family $3,000 individual / $6,000 family $5,000 individual / $10,000 family $10,000 individual / $20,000 family |
$4,000 individual / $8,000 family $6,000 individual / $12,000 family $10,00 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. |
$5,000 individual / $10,000 family $6,000 individual / $12,000 family $8,000 individual / $16,000 family $13,000 individual / $26,000 family |
$10,000 individual / $20,000 family $12,000 individual / $24,000 family $16,000 individual / $32,000 family $26,000 individual / $52,0000 family |
| Physician Office Visits | $30%1 for the first 2 office visits per person per calendar year. 3+ office visits - subject to deductible and 30% coinsurance | 40%1 for visits 1 and 2. 3+ office visits are not covered |
| Preventive Care Lab/X-Ray for routine Pap smear, annual mammogram, colorectal cancer screening or PSA screening ONLY. Other preventive care services are not covered. |
30%1 | 40%1 |
| Well Child Care | Not covered | |
| Diagnostic Services $300 maximum per member per calendar year for combined network and non-network (Includes lab work, X-rays and Outpatient Diagnostic Services. Preventive services excluded from the $300 limit) |
30%1 (not subject to deductible) | 40%1 (not subject to deductible) |
| Inpatient Hospital | 30%1 | 40%1 |
| Outpatient Services | 30%1 | 40%1 |
| Emergency Room | 30%1, (additional $60 co-pay if not admitted2) | 30%1, (additional $60 co-pay if not admitted2) |
| Urgent Care | 30%1 | 30%1 |
| Ambulance Includes air |
30%1 | 30%1 |
| Maternity Services | Not covered | |
| Optional Maternity | Not available | |
| Outpatient Therapy Services | Not covered | |
| Mental Health and Substance Abuse | Not covered | |
|
30%1 | 40%1 |
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$30 co-pay2,3 for the first 2 office visits per person per calendar year. 3+ office visits not covered | 40%1 for office visits 1 and 2. 3+ office visits not covered |
| Home Health Care Maximum visits per benefit period - 60 visits |
30%1 | 40%1 |
| Hospice | 30%1 | 30%1 |
| Durable Medical Equipment | Not covered | |
| Prosthetic Devices $4,000 maximum per benefit period |
30%1 | 40%1 |
| Human Organ and Tissue Transplant Services | 30%1 | 40%1 (coinsurance does not apply to out-of-pocket maximum) |
| 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 |
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$10 co-payment2 | Not covered |
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$200 deductible per calendar year, then $25 per prescription2 | Not covered |
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$10 co-payment2 | Not covered |
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Not covered | Not covered |
| Mail Service Up to a 90-day supply of maintenance drugs is available through mail service. |
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$20 co-payment2 | Not covered |
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$200 deductible per calendar year, then $50 per prescription2 | Not covered |
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Not covered | Not covered |
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Not covered | 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. 3Physician office visits and mental health office visits are combined for a maximum of 2 visits per person, per calendar year. Subsequent office visits are not covered. |
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| 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 Value Plan 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 Value Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail. |
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| 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! |