March 21, 2010

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Anthem Blue Cross and Blue Shield of Wisconsin – Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) – WISCONSIN

A comparison of the Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) offered by Anthem Blue Cross and Blue Shield of Wisconsin is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Application Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Application
Brochure Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Brochure Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Brochure
Copay $35 N/A
Office Visit Doctors' Office Visits: $35 Copayment for the first 2 visits only, visits 3+ are not covered (Office services are subject to deductible and coinsurance) Doctors' Office Visits: 50% Coinsurance for first 2 visits only, 3+ are not covered
Deductible Individual: $2,000, Family: $6,000 Individual: $4,000, Family: $12,000
Coinsurance 70% 50%
Coinsurance Limit Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible)
Out-of-Pocket Maximum Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible) Blue Access Value Rx Option $15/$30/$60/25% ($500 deductible)
Lifetime Maximum Unlimited Unlimited
Prescription Drugs Upgraded Drug Coverage ($500 per member deductible for Tiers 2 and 3) -
  • Retail Drugs (30-day supply) - Tier 1: $15 Copayment - Tier 2: $30 Copayment - Tier 3: $60 Copayment - Tier 4: 25% Coinsurance
  • Mail Order Drugs (90-day supply) - Tier 1: $30 Copayment - Tier 2: $75 Copayment - Tier 3: $150 Copayment - Tier 4: 25% Coinsurance
Tier 4: $2,500 annual prescription drug out-of-pocket maximum		 Upgraded Drug Coverage ($500 per member deductible for Tiers 2 and 3) -
  • Retail Drugs (30-day supply): 50% Coinsurance (Minimum $60) per prescription. Member is responsible for the difference between Anthem allowable amount and actual charge in addition to cost share
Emergency Room
  • Emergency Room Services: 70% Coinsurance
  • Ambulance: 70% Coinsurance
    		•
  • Emergency Room Services: 70% Coinsurance
  • Ambulance:70% Coinsurance (Member is responsible for charged amount that exceeds Anthem's maximum allowable amount)
    		•
    Adult Preventative Care Preventive Care Services (Includes Routine Pap test, annual mammogram, colorectal cancer screening or PSA screening only. Other preventive tests are not covered): 70% Coinsurance Preventive Care Services: Childhood immunizations are covered at 100% from birth through age 5 in network. Other well-child care services not included
    Child Preventative Care Preventive Care Services: Childhood immunizations are covered at 100% from birth through age 5 in network. Other well-child care services not included Preventive Care Services: Childhood immunizations are covered at 100% from birth through age 5 in network. Other well-child care services not included
    Lab / X-Ray 70% Coinsurance (Deductible waived, $300 annual maximum benefit network and non-network combined - Included lab work and X-rays) 50% Coinsurance (Deductible waived, $300 annual maximum benefit network and non-network combined - Included lab work and X-rays)
    Maternity Not covered (Except for complications of pregnancy only) Not covered (Except for complications of pregnancy only)
    Physical Therapy
  • Physical Therapy: 70% Coinsurance (20 visit max., Chiropractic Services are unlimited)
  • Occupational Therapy: 70% Coinsurance (20 visit max.)
  • Speech Therapy: 70% Coinsurance (20 visit max.)
  • Physical Medicine & Rehab: 70% Coinsurance (40 visit max.)
    		•
  • Physical Therapy: 50% Coinsurance (20 visit max., Chiropractic Services are unlimited)
  • Occupational Therapy: 50% Coinsurance (20 visit max.)
  • Speech Therapy: 50% Coinsurance (20 visit max.)
  • Physical Medicine & Rehab: 50% Coinsurance (40 visit max.)
    		•
    Skilled Nursing 70% Coinsurance (30 days per admission) 50% Coinsurance (30 days per admission)
    Home Health Care 70% Coinsurance (60 visit limit for network and non-network combined per calendar year) 50% Coinsurance (60 visit limit for network and non-network combined per calendar year)
    Mental Health Not covered (Except for Autism) Not covered (Except for Autism)
    Hospital Care
  • Professional and Diagnostic Services (X-ray, lab, anesthesia, surgeon, etc.): 70% Coinsurance (Deductible waived, $300 annual maximum benefit network and non-network combined - Includes Outpatient Diagnostic Services)
  • Inpatient Services (Overnight hospital/facility stays): 70% Coinsurance
  • Outpatient Services (Without overnight hospital/facility stays): 70% Coinsurance
  • Urgent Care: 70% Coinsurance
    		•
  • Professional and Diagnostic Services (X-ray, lab, anesthesia, surgeon, etc.): 50% Coinsurance (Deductible waived, $300 annual maximum benefit network and non-network combined - Includes Outpatient Diagnostic Services)
  • Inpatient Services (Overnight hospital/facility stays): 50% Coinsurance
  • Outpatient Services (Without overnight hospital/facility stays): 50% Coinsurance
  • Urgent Care: 50% Coinsurance (Member is responsible for charged amount that exceeds Anthem's maximum allowable amount)
    		•
    Optional Benefits Optional Coverage (At additional cost) -
    • Dental
    • Life
    		 Optional Coverage (At additional cost) -
    • Dental
    • Life