March 15, 2010

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Anthem Blue Cross and Blue Shield of Connecticut – Tonik 3000 – CONNECTICUT

A comparison of the Tonik 3000 offered by Anthem Blue Cross and Blue Shield of Connecticut is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Tonik 3000 Application Tonik 3000 Application
Brochure Tonik 3000 Brochure Tonik 3000 Brochure
Copay Preventive and Medical Office visits- $25 Copayment (deductible waived for the combined total of the first 4 preventive, medical and/or mental health and substance abuse visits in a Calendar Year) 50% after calendar year deductible
Office Visit Preventive and Medical Office visits- $25 Copayment (deductible waived for the combined total of the first 4 preventive, medical and/or mental health and substance abuse visits in a Calendar Year) 50% after calendar year deductible
Deductible $3,000 $3,000
Coinsurance N/A 50% after deductible
Coinsurance Limit N/A $7,000 per calendar year
Out-of-Pocket Maximum Tonik 3000 Tonik 3000
Lifetime Maximum $5,000,000 $5,000,000
Prescription Drugs
  • $500 calendar year maximum
  • Purchased at a participating retail pharmacy- 30 day supply
    • Tier 1 (Generic prescription drugs)- $10 Copayment
    • Tier 2 (Listed brand prescription drugs)- $25 Copayment
    • Tier 3 (Non listed brand prescription drugs)- $40 Copayment
  • Purchased by mail order- 90 day supply
    • Tier 1 (Generic prescription drugs)- $20 Copayment
    • Tier 2 (Listed brand prescription drugs)- $50 Copayment
    • Tier 3 (Non listed brand prescription drugs)- $80 Copayment
    		•
  • $500 calendar year maximum
  • Purchased at a participating retail pharmacy- 30 day supply
    • Tier 1 (Generic prescription drugs)- Member pays 20% after deductible
    • Tier 2 (Listed brand prescription drugs)- Member pays 20% after deductible
    • Tier 3 (Non listed brand prescription drugs)- Member pays 20% after deductible
  • Purchased by mail order- 90 day supply
    • Tier 1 (Generic prescription drugs)- Member pays 20% after deductible
    • Tier 2 (Listed brand prescription drugs)- Member pays 20% after deductible
    • Tier 3 (Non listed brand prescription drugs)- Member pays 20% after deductible
    		•
    Emergency Room $100 Copayment (deductible waived) (copayment waived if admitted) $100 Copayment (deductible waived) (copayment waived if admitted)
    Adult Preventative Care
  • Preventive and Medical Office visits- $25 Copayment (deductible waived for the combined total of the first 4 preventive, medical and/or mental health and substance abuse visits in a Calendar Year)
  • Routine ancillary services performed as part of a preventive exam (including but not limited to: pap tests, breast exams, mammography, and PSA tests)- $0 (deductible waived)
    		•
  • Preventive and Medical Office visits- 50% after deductible
  • Routine ancillary services performed as part of a preventive exam- 50% after deductible
  • Well Child Care (including immunizations):
    • 6 exams, birth to age 1
    • 6 exams, ages 1-5
    • 1 exam every 2 years, ages 6-10
    • 1 exam every year, ages 11-21
    		•
    Child Preventative Care
  • Preventive and Medical Office visits- $25 Copayment (deductible waived)
  • Routine ancillary services performed as part of a preventive exam- $0 (deductible waived)
  • Well Child Care (including immunizations):
    • 6 exams, birth to age 1
    • 6 exams, ages 1-5
    • 1 exam every 2 years, ages 6-10
    • 1 exam every year, ages 11-21
    		•
  • Preventive and Medical Office visits- 50% after deductible
  • Routine ancillary services performed as part of a preventive exam- 50% after deductible
  • Well Child Care (including immunizations):
    • 6 exams, birth to age 1
    • 6 exams, ages 1-5
    • 1 exam every 2 years, ages 6-10
    • 1 exam every year, ages 11-21
    		•
    Lab / X-Ray $0 after deductible 50% after deductible
    Maternity Not Covered Not Covered
    Physical Therapy Rehabilitative services (up to 100 days per person per calendar year)- $0 after deductible Rehabilitative services (up to 100 days per person per calendar year)- 50% after deductible
    Skilled Nursing $0 after deductible (up to 100 days per calendar year) 50% after deductible (up to 100 days per calendar year)
    Home Health Care $0 after deductible (up to 80 visits per member per calendar year) $50 deductible and member pays 20% coinsurance (up to 80 visits per member per calendar year)
    Mental Health
  • Inpatient Services- $0 after deductible
  • Professional Services- $30 Copayment (deductible waived for the combined total of the first 4 preventive, medical and/or mental health and substance abuse visits in a Calendar Year)
    		•
  • Inpatient Services- 50% after deductible
  • Professional Services- 50% after deductible
    		•
    Hospital Care
  • Semi-private room (General/Medical/Surgical)- $0 after deductible
  • Outpatient surgery (in a hospital or surgi-center)- $0 after deductible
    		•
  • Semi-private room (General/Medical/Surgical)- 50% after deductible
  • Outpatient surgery (in a hospital or surgi-center)- 50% after deductible
    		•
    Optional Benefits Tonik 3000 Tonik 3000