Anthem Blue Cross and Blue Shield - Blue Access Economy 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. |
$500 individual / $1,000 family $1,000 individual / $2,000 family $1,500 individual / $3,000 family $2,500 individual / $5,000 family |
$1,500 individual / $3,000 family $2,000 individual / $4,000 family $2,500 individual / $5,000 family $3,500 individual / $7,000 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. |
$3,500 individual / $7,000 family $4,000 individual / $8,000 family $4,500 individual / $9,000 family $5,500 individual / $11,000 family |
$7,500 individual / $15,000 family $8,000 individual / $16,000 family $8,500 individual / $17,000 family $9,500 individual / $19,000 family |
| Physician Office Visits | $30%1 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30% coinsurance | 50%1 |
| Preventive Care | Not covered | |
| Well Child Care | Not covered | |
| Diagnostic Services | 30%1 | 50%1 |
| Inpatient Hospital | 30%1 | 50%1 |
| Outpatient Services | 30%1 | 50%1 |
| Emergency Room | 30%1 | 30%1,4 |
| Urgent Care | 30%1 | 30%1 |
| Ambulance Includes air |
30%1 | 30%1 |
| Maternity Services | Not covered | |
| Optional Maternity | Not available | |
| Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined: |
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$30%1 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30% coinsurance | 50%1 |
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$30%1 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30% coinsurance | 50%1 |
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$30%1 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30% coinsurance | 50%1 |
| Mental Health and Substance Abuse | Not covered | |
| Home Health Care Maximum visits per benefit period - 60 visits |
30%1 | 50%1 |
| Hospice | 30%1 | 50%1 |
| Durable Medical Equipment $4,000 maximum per benefit period |
30%1 | 50%1 |
| Prosthetic Devices $4,000 maximum per benefit period |
30%1 | 50%1 |
| Human Organ and Tissue Transplant Services Kidney and cornea transplant services covered same as any other illness under medical. Includes transportation, lodging, and meals. |
30%1 | 50%1 |
| 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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$15 co-payment2, $500 maximum per person per calendar year | 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. |
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. 3$30 copayment for the first 3 office visits includes Physician office visits and Outpatient Therapy office visits combined. Subsequent office visits subject to the deductible and 30% coinsurance. 4Emergency Care rendered by a Non-network Provider will be covered as a Network service, however, the member may be responsible for the difference between the Non-network Provider's charge and the amount that Anthem determines is the maximum amount payable for covered services the member receives, in addition to any applicable copayment or deductible. |
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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 Economy 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 Economy 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! |