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Plan Type EPO
Office Visit for Primary Doctor
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$35 for 2 visits then 25% coinsurance after deductible
Office Visit for Specialist 25% coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 for 2 visits then 25% coinsurance after deductible
Annual Deductible Individual: $2,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 25% after deductible
Retail Prescription Drugs Tier 1: 25% Coinsurance after deductible;Tier 2: 25% Coinsurance after deductible;Tier 3: 25% Coinsurance after deductible;Tier 4: 25% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $6,350
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $200 copay and 25% coinsurance after deductible
Emergency Ambulance Services 25% coinsurance after deductible
Urgent Care Facility $50 copay then 25% coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Tier 1: 25% Coinsurance after deductible;Tier 2: 25% Coinsurance after deductible;Tier 3: 25% Coinsurance after deductible;Tier 4: 25% Coinsurance after deductible
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Combined with Medical
Mail Order Supply 90 Day
Outpatient Coverage
Outpatient Surgery 25% Coinsurance after deductible
Outpatient Lab/X-Ray 25% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 25% Coinsurance after deductible
Outpatient Mental Health 25% Coinsurance after deductible
Outpatient Substance Abuse 25% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 25% Coinsurance after deductible
Inpatient Coverage
Hospitalization 25% Coinsurance after deductible
Skilled Nursing Facility 100 days; 25% Coinsurance after deductible
Inpatient Mental Health 25% Coinsurance after deductible
Inpatient Substance Abuse 25% Coinsurance after deductible
Home Healthcare 100 Visits: 25% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit No charge
Labor & Delivery Hospital Stay 25% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge
Eye Glasses for Children No Charge
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 25% Coinsurance after deductible
Hospice 25% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A as of 06/06/2014
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure (Not available)

The carrier has not provided a separate document for Exclusions and Limitations.

Summary of Benefits & Coverage (Not available)

The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Customer reviews

Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Anthem Blue Cross - All medical plans and rates are subject to regulatory approval. We will continue to add to our plan offerings on this site as we obtain regulatory approvals. Please keep checking back. All benefits are subject to deductible unless specified otherwise.