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Blue Cross Anthem Blue Cross (HMO) Plans Non-Grandfathered Plans Effective January 1, 2012
Benefit Description	HMO 100%	HMO 80%
Annual Deductible	None	None
Annual Out-of-Pocket Maximum	$1,750 Individual $3,500 Family	$5,000 Individual $10,000 Two-Party $15,000 Family
Professional Services
Office Visits	$10 per visit	$15 per visit
Specialist & Consultants	$10 per visit	$30 per visit
Hospital
Emergency Care Co-pay waived if admitted	$100 per visit	$100 per visit
Inpatient Hospital Services and Surgical Facilities	No charge	20% of charges
Other Professional Services	No charge	20% of charges
Outpatient Medical Services	No charge	No charge
Health Maintenance
Outpatient Annual Physical Examination, Well Woman and Well Baby Care	No charge	No charge
Mental and Nervous and Substance Abuse*
Inpatient	No charge	20% of charges
Outpatient	No charge	No charge
Other Services
Home Health Care (90 visits per year)	No charge	$15 per visit
Physical Therapy, Occupational Therapy, Chiropractic Care (60-day period of care)	No charge	$15 per visit
Prescription Drugs
Prescription Drug Deductible	$150 Brand Deductible per member	$150 Brand Deductible per member
Participating Pharmacies (30-day supply)	$10 Generic $25 Brand-Formulary $45 Brand-Non-Formulary	$10 Generic $25 Brand-Formulary $45 Brand-Non-Formulary
Mail Order (60-day supply)	$10 Generic $25 Brand-Formulary $45 Brand-Non-Formulary	$10 Generic $25 Brand-Formulary $45 Brand-Non-Formulary
Self Administered Injectable Drugs (Retail or Mail Order) (Excluding Insulin)	30% of prescription drug maximum allowed amount	30% of prescription drug maximum allowed amount
Note: This summary is a brief review of benefits. It is not a contract and does not replace the master policy. It is as accurate as possible, but we cannot be responsible for any errors and make no warranty of any kind. *In order or receive coverage, services must be rendered by a Anthem Blue Cross behavioral health provider. Prescription drug benefits are provided through Express Scripts, Inc. Specialty drugs are provided through CuraScript.