Professional Documents
Culture Documents
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at http://www.anthem.com/ca or by calling 1-855-333-5730.
Important Questions
Is there an outof
pocket limit on my
expenses?
What is not included in
the outofpocket
limit?
Is there an overall
annual limit on what
the plan pays?
Answers
For PPO Providers
$250 Member/$500 Family
For Non-PPO Providers
$250 Member/$500 Family
Does not apply to Preventive Care, Office Visit
Copayments, Hospice and Prescription Drugs.
PPO Provider and Non-PPO Provider deductibles
are separate and do not count towards each other.
Yes. $500/Admission for Non-Anthem Blue
Cross PPO hospital or residential treatment center
if utilization review not obtained (waived for
emergency admission).
$150/Visit for Emergency Room services (waived
if admitted directly from ER).
Yes. For PPO Providers
$1,500 Member/$3,000 Family
For Non-PPO Providers
$3,000 Member/$6,000 Family
PPO Provider and Non-PPO Provider out-ofpocket are separate and do not count towards each
other.
You must pay all of the costs for these services up to the specific
deductible amount before this plan begins to pay for these services.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they dont count toward the outof
pocket limit.
No.
The chart starting on page 2 describes any limits on what the plan will pay
for specific covered services, such as office visits.
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If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your in-network
doctor or hospital may use an out-of-network provider for some services.
Plans use the term in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
Do I need a referral to
see a specialist?
You can see the specialist you choose without permission from this plan.
Yes.
Some of the services this plan doesnt cover are listed on page 8. See your
policy or plan document for additional information about excluded
services.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use PPO providers by charging you lower deductibles, copayments and coinsurance amounts.
Your Cost If
You Use a
PPO
Provider
Common
Medical Event
Your Cost If
You Use a
Non-PPO Provider
30% Coinsurance
--------none--------
30% Coinsurance
--------none--------
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Common
Medical Event
Your Cost If
You Use a
PPO
Provider
Your Cost If
You Use a
Non-PPO Provider
Chiropractor
10% Coinsurance
Acupuncturist
10% Coinsurance
Chiropractor
30% Coinsurance
Acupuncturist
30% Coinsurance
Chiropractor
Coverage is limited to 24 visits per
benefit period. Additional visits may
be authorized. Services from InNetwork and Non-Network
providers count towards your benefit
period limit. Chiropractic visits
count towards your physical and
occupational therapy limit.
Acupuncturist
Coverage is limited to 12 visits for
In-Network and Non-Network
providers/per benefit period.
Preventive care/screening/
immunization
No Cost Share
30% Coinsurance
--------none--------
Lab Office
10% Coinsurance
X-Ray Office
10% Coinsurance
Lab Office
30% Coinsurance
X-Ray Office
30% Coinsurance
--------none--------
30% Coinsurance
10% Coinsurance
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Common
Medical Event
If you have
outpatient surgery
Your Cost If
You Use a
PPO
Provider
$10 Copay/
prescription (retail
and home delivery)
$25 Copay/
prescription (retail)
$50 Copay/
prescription (home
delivery)
$45 Copay/
prescription (retail)
$90 Copay/
prescription (home
delivery)
Your Cost If
You Use a
Non-PPO Provider
$10 Copay/ prescription
plus 50% of the remaining
prescription drug
maximum allowed amount
and costs in excess of the
prescription drug
maximum allowed amount
$25 Copay/ prescription
plus 50% of the remaining
prescription drug
maximum allowed amount
and costs in excess of the
prescription drug
maximum allowed amount
$45 Copay/ prescription
plus 50% of the remaining
prescription drug
maximum allowed amount
and costs in excess of the
prescription drug
maximum allowed amount
20% Coinsurance
(retail only) with
$150 max and
20% Coinsurance
(home delivery)
with $300 max
50% Coinsurance
10% Coinsurance
30% Coinsurance
Physician/surgeon fees
10% Coinsurance
30% Coinsurance
Common
Medical Event
If you need
immediate medical
attention
If you have a
hospital stay
Your Cost If
You Use a
PPO
Provider
Your Cost If
You Use a
Non-PPO Provider
10% Coinsurance
10% Coinsurance
10% Coinsurance
10% Coinsurance
Urgent care
$15 Copay/Visit
30% Coinsurance
10% Coinsurance
30% Coinsurance
Physician/surgeon fee
10% Coinsurance
30% Coinsurance
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Common
Medical Event
Your Cost If
You Use a
PPO
Provider
Mental/Behavioral
Health Office Visit
$15 Copay/Visit
Mental/Behavioral
Health Facility Visit
Facility Charges
10% Coinsurance
Your Cost If
You Use a
Non-PPO Provider
Mental/Behavioral Health
Office Visit
30% Coinsurance
Mental/Behavioral Health
Facility Visit Facility
Charges
30% Coinsurance
--------none--------
10% Coinsurance
30% Coinsurance
Substance Abuse
Office Visit
$15 Copay/Visit
Substance Abuse
Facility Visit
Facility Charges
10% Coinsurance
--------none--------
10% Coinsurance
30% Coinsurance
10% Coinsurance
30% Coinsurance
10% Coinsurance
30% Coinsurance
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Common
Medical Event
Your Cost If
You Use a
PPO
Provider
Your Cost If
You Use a
Non-PPO Provider
10% Coinsurance
30% Coinsurance
Rehabilitation services
10% Coinsurance
30% Coinsurance
Habilitation services
10% Coinsurance
30% Coinsurance
10% Coinsurance
30% Coinsurance
10% Coinsurance
No Cost Share
Not Covered
Not Covered
Not Covered
30% Coinsurance
30% Coinsurance
Not Covered
Not Covered
Not Covered
Cosmetic surgery
Long-term care
Private-duty nursing
Hearing aids
Infertility treatment
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Acupuncture
Chiropractic care
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To see examples of how this plan might cover costs for a sample medical situation, see the next page.
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This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
(routine maintenance of
a well-controlled condition)
(normal delivery)
Amount owed to providers: $7,540
Plan pays: $6,420
Patient pays: $1,120
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$250
$550
$120
$80
$1,000
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$250
$20
$700
$150
$1,120
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