In-Network Benefits

Non-Grandfathered Plans Effective January 1, 2012

Annual Deductible (combined in/out-of-network)

$250 per member
$500 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met

$250 per member
$500 family aggregate
Generally, all medical benefits are covered only after the plan’s deductible has been met

$500 per member
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan's deductible has been met unless otherwise stated

$500 per member
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan’s deductible has been met

$1,500 per member
$3,000 family aggregate
Generally, all medical benefits are covered only after the plan’s deductible has been met

$0

No in-network deductible

Out-of-Pocket Maximum (annual)

$2,500 per member
$5,000 family aggregate

$3,000 per member
$6,000 family aggregate

$4,000 per member
$8,000 family aggregate

$5,000 per member
$10,000 family aggregate

$5,000 per member
$10,000 family aggregate

$8,000 per member
$16,000 family aggregate
Plus hospital admission deductible
($3,000 per person) if applicable.

Lifetime Maximum Benefit

None
$2,000,000 calendar year maximum

None
$2,000,000 calendar year maximum

None
$2,000,000 calendar year maximum

None
$2,000,000 calendar year maximum

None
$2,000,000 calendar year maximum

None
$2,000,000 calendar year maximum

Hospital Admission Copay

(Includes Mental & Nervous and Substance Abuse Admissions)

NA

NA

NA

NA

NA

First hospital admission only per person, per year $3,000 copay

Inpatient & Outpatient Hospital Services

10% of negotiated fee

20% of negotiated fee

30% of negotiated fee

40% of negotiated fee

40% of negotiated fee

50% of negotiated fee

Emergency Room Deductible

$100³

$100³

$100³

$100³

$100³

$100³

Office Visits

$10 copay per visit

$15 copay per visit.

First 6 in-network visits per calendar year are not subject to the deductible.

(combined with in-network mental & nervous and substance abuse outpatient visits)

$25 copay per visit.

First 6 in-network visits per calendar year are not subject to the deductible.

(combined with in-network mental & nervous and substance abuse outpatient visits)

$35 copay per visit.

First 6 in-network visits per calendar year are not subject to the deductible

(combined with in-network mental & nervous and substance abuse outpatient visits) .

$40 copay per visit.

First 6 in-network visits per calendar year are not subject to the deductible

(combined with in-network mental & nervous and substance abuse outpatient visits) .

$45 copay per visit

Preventive (ages 7 and up, including well-woman care)
1 Physical per year

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Well-Baby Care (ages 0-6)

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Not subject to the deductible, 100% plan paid

Prescription Drugs
Annual Deductible

(combines in-/out-of-network charges)

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

$150 per person⁵
Applies to brand-name drugs only
$300 family aggregate

Specialty Pharmacy Program

Some drugs for typically rare and chronic diseases are only available through the specialty drug mail order program.

Prescription Drugs - Retail
(30 day supply)

Generic

$10 copay

$10 copay

$10 copay

$10 copay

$10 copay

$10 copay

Brand - Formulary

$25

$25

$25

$25

$25

$25

Brand - Non-Formulary

$45

$45

$45

$45

$45

$45

Prescription Drugs - Mail Order
(60 day supply)
Mail order is available only through Anthem Blue Cross Express Scripts

Generic

$10 copay

$10 copay

$10 copay

$10 copay

$10 copay

$10 copay

Brand - Formulary

$25

$25

$25

$25

$25

$25

Brand - Non-Formulary

$45

$45

$45

$45

$45

$45

Self-injectable drugs
(excluding insulin)
(Retail or mail order)

30% of prescription drug maximum allowed amount

30% of prescription drug maximum allowed amount

30% of prescription drug maximum allowed amount

30% of prescription drug maximum allowed amount

30% of prescription drug maximum allowed amount

30% of prescription drug maximum allowed amount

Mental & Nervous/Substance Abuse
Inpatient

10% of negotiated fee

20% of negotiated fee

30% of negotiated fee

40% of negotiated fee

40% of negotiated fee

50% of negotiated fee

Mental & Nervous/Substance Abuse
Office Visits/Therapy Sessions

$10 copay

$15 copay

$25 copay

$35 copay

$40 copay

$45 copay

Mental & Nervous/Substance Abuse
(First Hospital admission per year)

None

None

None

None

None

$3,000 copay

Mental & Nervous/Substance Abuse
Outpatient

10% of negotiated fee

20% of negotiated fee

30% of negotiated fee

40% of negotated fee

40% of negotated fee

50% of negotiated fee