| Copay |
$30 |
N/A |
| OfficeVisit |
Office Visit $30 Copay for primary care physician; $50 Copay for specialist (deductible waived for both) |
50% Coinsurance (after deductible) |
| Deductible |
|
|
| Coinsurance |
25% |
50% |
| Coinsurance Limit |
|
|
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Retail Drugs (and Mail Order Drugs when available) -
- Tier 1 (Generic Drugs): $15 Copay
- $500 annual Prescription Drug deductible per member applies before the following -
- Tier 2 (Formulary Brand Name Drugs): $40 Copay
- Tier 3 (Non-Formulary Brand Name Drugs): $60 Copay
- Specialty: 25% Coinsurance up to a $2,500 annual Prescription Drug out-of-pocket maximum (the most you'll have to pay), network only and in addition to $500 annual deductible
|
Retail Drugs (and Mail Order Drugs when available): Same benefits as network, plus any difference in cost between the actual charges and Anthem's allowed amount |
| Emergency Room |
25% Coinsurance (after deductible) |
25% Coinsurance (after deductible) |
| Adult Preventative Care |
0% Coinsurance, not subject to deductible (Includes all nationally recommended preventive services including immunizations, PSA screenings, Pap tests, mammograms and more) |
50% Coinsurance (Includes all nationally recommended preventive services including immunizations, PSA screenings, Pap tests, mammograms and more) |
| Child Preventative Care |
0% Coinsurance, not subject to deductible (Includes all nationally recommended preventive services including well-child care, immunizations and more) |
50% Coinsurance (Includes all nationally recommended preventive services including well-child care, immunizations and more) |
| Lab / X-Ray |
25% Coinsurance (after deductible) |
50% Coinsurance (after deductible) |
| Maternity |
Not Covered |
Not Covered |
| Physical Therapy |
Benefits Included, see brochure for more coverage details |
Benefits Included, see brochure for more coverage details |
| Home Health Care |
Benefits Included, see brochure for more coverage details |
Benefits Included, see brochure for more coverage details |
| Mental Health |
Benefits Included, see brochure for more coverage details |
Benefits Included, see brochure for more coverage details |
| Hospital Care |
Inpatient Services (overnight hospital/facility stays): 25% after deductible
Outpatient Services (without overnight hospital/facility stays): 25% after deductible |
Inpatient Services (overnight hospital/facility stays): 50% after deductible
Outpatient Services (without overnight hospital/facility stays): 50% after deductible |
