Anthem Blue Cross and Blue Shield - BluePreferred PPO
| BluePreferred PPO |
|---|
The BluePreferred PPO plan generally offers the best value for full, comprehensive coverage that includes hospitalization, doctor visits ($25 co-pay, with NO limits on the number of covered visits), and prescription and vision coverage.
The prescription program offers you generic drugs for just $15, brand name drugs for $40, and drugs that are not listed on the formulary list for a $60 co-payment. There is also a $500 accident benefit that covers the first $500 for any accident with a zero deductible. The vision coverage includes eye exams for a $25 co-pay, and lenses and frames for a $25 co-pay.
Other BluePreferred PPO features include:
- A choice of deductibles, which gives you more control over your premium costs.
- Access to one of the largest PPO networks in Colorado with more than 6,500 doctors and 80 hospitals
- No referrals needed to see in-network specialists
- Preventive care benefits for well-child physician office visits, immunizations for children, and health screenings such as mammograms, pap tests and prostate cancer screenings.
- Non-routine doctor visits are covered at 100% after your copay (certain exceptions may apply)
- Out-of-state coverage through the BlueCard program when you're traveling
BluePreferred PPO - Outline of Coverage
| Plan Feature | In-Network You Pay | Out-of-Network You Pay3 |
| Deductible Options For families, each family member receives their own individual deductible. For example, if a family chooses the BluePreferred $500 deductible plan, each family member has their own $500 deductible. |
$500 individual / $500 per family member $1,000 individual / $1,000 per family member $2,000 individual / $2,000 per family member $3,000 individual / $3,000 per family member |
$1,000 individual / $1,000 per family member $2,000 individual/ $2,000 per family member $4,000 individual/ $4,000 per family member $6,000 individual/ $6,000 per family member |
| Out-of-Pocket Expense Limit Includes deductible. |
$1,500 individual / $1,500 per family member1 $2,000 individual / $2,000 per family member1 $3,000 individual / $3,000 per family member1 $5,000 individual / $5,000 per family member1 |
$3,000 individual / $3,000 per family member1 $4,000 individual / $4,000 per family member1 $6,000 individual / $6,000 per family member1 $9,000 individual / $9,000 per family member1 |
| Accident Benefit Covers the first $500 for any accident with a zero deductible |
$500 additional accident benefits per member per accident | |
| Lifetime Maximum Benefit | $2,000,000 per person | |
| Physician Office Visits | $25 co-pay for office visits2, 20% for other services | 40% |
| Professional Services X-ray, lab, anesthesia, surgeon, etc. |
20%4 | 40%4 |
| Urgent Care | 20%4 | 40%4 |
| Hospital Inpatient (Overnight hospital stays) |
20%4 | 40%4 |
| Hospital Outpatient (Non-overnight hospital stays) |
20%4 | 40%4 |
| Emergency Room | 20%4 | 40%4 |
| Maternity | Not Covered | |
| Preventive Care Includes appropriate screenings for breast, cervical, ovarian, and prostate cancer |
Mammogram and PSA test covered at no cost For Pap tests, Anthem will pay $75 per test. Member is responsible any charges over this amount plus office visit copay or coinsurance shown above |
Member is responsible for any charges in excess of Anthem's Maximum Benefit Allowance (MBA) |
| Well Child Care | 20% for age-appropriate visits and routine immunizations (deductible waived) | 40% for age-appropriate visits and routine immunizations (deductible waived) |
| Ambulance Maximum benefit of $350 per ground trip, $5,000 per air trip. |
20%4 | 40%4 |
| Mental Health Care | Maximum payment for inpatient and outpatient care is limited to $10,000 per member per lifetime. | |
|
50%4 | 50%4 |
|
50%4 | 50%4 |
| Alcohol & Substance Abuse | Not Covered | |
| Physical, Occupational, and Speech Therapy | ||
|
20%4 | 40%4 |
|
20%4 | 40%4 |
| Durable Medical Equipment | 20%4 | 40%4 |
| Chiropractic Services | Not Covered | |
| Oxygen | 20%4 | 40%4 |
| Organ Transplants | 20% | 40% |
| Home Health Care Limited to 60 visits per member in each benefit year, in and out-of-network combined. |
20% | 40% |
| Hospice Care | ||
|
20%4 | 40%4 |
|
20%4 | 40%4 |
| Skilled Nursing Facility Care | Not Covered | |
| Dental Care | Not Covered | |
| Outpatient Prescription Drug Benefit | In-Network You Pay | Out-of-Network You Pay |
| Retail Up to a 34 day supply |
||
|
$15 co-payment | Not Covered |
|
$40 co-payment | Not Covered |
|
$60 co-payment | Not Covered |
| Mail Service Up to a 90-day supply of maintenance drugs is available through mail service. |
||
|
$30 co-payment | Not covered |
|
$80 co-payment | Not covered |
|
$120 co-payment | Not covered |
| Vision Benefits | In-Network You Pay | Non-Network Reimbursement |
| Vision Exam Each member is entitled to comprehensive vision exam every 12 months |
$25 co-payment | Up to $35 |
| Lenses A choice of glass or plastic (CR39) lenses in single vision, and bifocal or trifocal (FT 25-28) lenses up to 55 mm and all ranges of prescriptions once every 12 months. |
||
|
$25 co-payment | Up to $25 |
|
$25 co-payment | Up to $40 |
|
$25 co-payment | Up to $40 |
|
$25 co-payment | Up to $55 |
|
$25 co-payment | Up to $80 |
| Frames Maximum allowable amount of $120 (retail) for frames purchases from network provider every 24 months. Member pays preferred price in excess of maximum allowable amount. |
$25 co-payment | Up to $45 |
| Contact Lenses | ||
|
$25 co-payment Plan provides 10% discount on disposable and 15% discount on traditional lenses. |
Up to $80 |
|
$25 co-payment | Up to $210 |
| Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility. | ||
| 1No single family member can contribute more than their individual out-of-pocket maximum toward meeting the family annual out-of-pocket maximum 2Only some services are covered as part of an office visit. All other covered services are subject to applicable coinsurance or cost-sharing. 3If you receive services from a non-participating provider, you will pay the coinsurance plus any difference between our Maximum Benefit Amount (MBA) and the provider's billed charges. 4Services subject to calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other. 5Tier 1 Drugs - Nearly all Tier 1 drugs are Preferred Generic Prescription Drugs, but Tier 1 may also include some lower cost brand-name drugs with the greatest therapeutic value. Tier 2 Drugs - Preferred Brand-Name and/or Generic Drugs that are lower-cost and provide greater therapeutic value than comparable brand-name drugs. Tier 3 Drugs - Nearly all Tier 3 drugs are Brand-Name drugs that cost more or are less efficient than comparable drugs on lower tiers, but Tier 3 may also include some high-cost generic drugs. If you purchase a brand-name drug when there is a FDA rated equivalent drug available, you are responsible for the Tier-2 and Tier-3 Copayment for brand-name drugs and you will pay the difference between the cost of the brand-name and the cost of the generic. For example: a Tier-3 brand-name prescription costs $50; a generic Tier-1 substitution is available, the generic prescription costs $20, you pay the $30 difference plus the Tier-3 Copayment. The $30 difference is not applied towards any other cost-sharing requirement. |
||
| 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 BluePreferred PPO 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 BluePreferred PPO Benefits Overview, the terms of the contract or certificate of coverage will prevail. |
||
| 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! |