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Plan Type PPO
Office Visit for Primary Doctor
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First 2 Office Visits (per member): $40 copay, deductible waived
Additional Office Visits: 100% of negotiated fee; then 0% Coinsurance after out-of-pocket maximum is met
Office Visit for Specialist First 2 Office Visits (per member): $40 copay, deductible waived
Additional Office Visits: 100% of negotiated fee; then 0% Coinsurance after out-of-pocket maximum is met
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $3,300
Separate Prescription Drugs Deductible $7,500 per member for Brand and Non-formulary drug only
Coinsurance 40% after deductible
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $6,800
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Emergency Care Only.
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam 0% Coinsurance, not subject to deductible
Periodic OB-GYN Exam 0% Coinsurance, not subject to deductible
Well Baby Care 0% Coinsurance, not subject to deductible
Emergency and Urgent Care
Emergency Room 40% Coinsurance after deductible plus $100 Emergency Room copay (copay waived if admitted)
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible $7,500 per member for Brand and Non-formulary drug only
Mail Order Prescription Drugs N/A
Mail Order Supply 90
Outpatient Coverage
Outpatient Surgery 40% Coinsurance after deductible
Outpatient Lab/X-Ray Inpatient: 40% Coinsurance after deductible
Outpatient: 100% of negotiated fee; then 0% Coinsurance after out-of-pocket maximum is met
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 40% Coinsurance after deductible
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Not Covered
Labor & Delivery Hospital Stay Not Covered
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $3,300 individual/$6,600 family
Out-of-Network Annual Coinsurance 40% after deductible for Inpatient
0% after deductible for outpatient
Out-of-Network Annual Out-of-Pocket Limit $6,800 individual/$13,600 family
Includes deductible
Additional Information
A.M. Best Rating A as of 04/25/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure 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.