March 14, 2010

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Anthem Blue Cross and Blue Shield of New Hampshire – Tonik 1500 – NEW HAMPSHIRE

A comparison of the Tonik 1500 offered by Anthem Blue Cross and Blue Shield of New Hampshire 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 1500 Application Tonik 1500 Application
Brochure Tonik 1500 Brochure Tonik 1500 Brochure
Copay $40 per visit $40 per visit
Office Visit $40 per visit Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
Deductible $1,500 deductible per member per calendar year $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
Coinsurance 0% coinsurance 50% coinsurance up to $8,500 per member per calendar year
Coinsurance Limit N/A N/A
Out-of-Pocket Maximum N/A N/A
Lifetime Maximum $5,000,000 $5,000,000
Prescription Drugs
  • Prescription Drugs (generic only)$10 co-payment (co-payment applies to each fill, up to a 30-day supply; you pay the generic co-payment for diabetic supplies)
  • Mail Order (generic prescription drugs only)$20 co-payment (co-payment applies to each fill, up to a 90-day supply)
    		•  Not covered
    Emergency Room
  • Emergency Room (ER Visit)ER physician fee, CT scan, MRI, medical supplies: Subject to $1,500 deductible per member per calendar year
  • ER charge (co-payment waived if admitted): $100 per visitAmbulance (medically necessary emergency transport only): Subject to $1,500 deductible per member per calendar year
    		•
  • Emergency Room (ER Visit)ER physician fee, CT scan, MRI, medical supplies: Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
  • ER charge (co-payment waived if admitted): $100 per visitAmbulance (medically necessary emergency transport only): Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
    		•
    Adult Preventative Care Routine ancillary services (prostate screening, screening mammography, pap smears, colorectal cancer screening, cholesterol screening, and preventive immunizations and vaccines): Covered in full Tonik 1500
    Child Preventative Care Tonik 1500 Tonik 1500
    Lab / X-Ray Subject to $1,500 deductible per member per calendar year Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
    Maternity Maternity care (prenatal, admission, delivery, post-partum) is covered only if you have purchased a maternity rider Maternity care (prenatal, admission, delivery, post-partum) is covered only if you have purchased a maternity rider
    Physical Therapy Subject to $1,500 deductible per member per calendar year Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
    Skilled Nursing Subject to $1,500 deductible per member per calendar year (up to 100 inpatient days per member per calendar year) Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year (up to 100 inpatient days per member per calendar year)
    Home Health Care Subject to $1,500 deductible per member per calendar year (up to 60 visits per member per calendar year) Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year (up to 60 visits per member per calendar year)
    Mental Health
  • Outpatient services (visit/consultation): Subject to deductible
  • Inpatient services (semi-private room and board, MH/SA physician visit; substance abuse services are limited to detoxification only): Subject to deductible (Inpatient and outpatient mental health and substance abuse benefits (combined) are limited to $3,000 per member per year and $10,000 per member per lifetime. Any combination of network and out-of-network benefits counts toward this maximum)
    		•
  • Outpatient services (visit/consultation): Subject to deductible and coinsurance
  • Inpatient services (semi-private room and board, MH/SA physician visit; substance abuse services are limited to detoxification only): Subject to deductible and coinsurance (Inpatient and outpatient mental health and substance abuse benefits (combined) are limited to $3,000 per member per year and $10,000 per member per lifetime. Any combination of network and out-of-network benefits counts toward this maximum)
    		•
    Hospital Care Subject to $1,500 deductible per member per calendar year Subject to $1,500 deductible per member per calendar year and 50% coinsurance up to $8,500 per member per calendar year
    Optional Benefits Tonik 1500 Tonik 1500