Annual Deductible
$1,500 per member*
$3,000 per family**
$2,500 per individual*
$5,000 per family**
$2,850 per member*
$5,650 per family**
Annual Out-of-Pocket Maximum
$4,500 per member*
$9,000 per family**
$2,500 per individual*
$5,000 per family**
$5,500 per member*
$11,000 per family**
Lifetime Maximum Benefit
$5,000,000
($2,000,000 cal. year max.)
$5,000,000
($2,000,000 cal. year max.)
$5,000,000
($2,000,000 cal. year max.)
Office Visits
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Other Professional Services
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Emergency Care
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Inpatient Hospital Services and Surgical Facilities
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Other Professional Services
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Well Woman Care
Not subject to the deductible
30% of negotiated fee, 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible
30% of negotiated fee, 1 visit/year
Well Baby Care
30% of negotiated fee after deductible
Not subject to the deductible, 100% plan paid.
30% of negotiated fee after deductible
Preventive Care (Ages 7 & Up) 1 Physical Per Year Deductible Does Not Apply
Plan pays up to $250, then you pay balance at 30% of the negotiated rate
Plan pays first $250 of covered expense, which is not subject to the deductible. Plan pays 100% of remaining charges after deductible is met
Plan pays up to $250, then you pay balance at 30% of the negotiated rate
Inpatient Nervous and Mental
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Outpatient Nervous and Mental Professional Services Day Care
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Inpatient Substance Abuse
30% of negotiated fee after deductible,
100% paid after deductible
30% of negotiated fee after deductible,
Outpatient Substance Abuse
30% of negotiated fee after deductible,
100% paid after deductible
30% of negotiated fee after deductible,
Physical Therapy, Occupational Therapy, Chiropractic Care
30% of negotiated fee after deductible,
25 visits/year
100% paid after deductible, max. 25 visits/year (combined with out-of-network visits)
30% of negotiated fee after deductible,
25 visits/year
Acupuncture
30% of negotiated fee after deductible.
Plan pays up to $60/visit after deductible,
max. 12 visits/year
100% paid after deductible. Plan pays up to $60/visit, max. 12 visits/year (combined with out-of-network visits)
30% of negotiated fee after deductible.
Plan pays up to $60/visit,
max. 12 visits/year
Durable Medical Equipment
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
Skilled Nursing Facility
30% of negotiated fee after deductible,
100 days/year
100% paid after deductible, up to 100 days per year (combined in/out-of-network)
30% of negotiated fee after deductible,
100 days/year
Hospice Care
30% of negotiated fee after deductible,
up to the $5,000 lifetime max.
100% paid after deductible,
up to $5,000 lifetime maximum
30% of negotiated fee after deductible,
up to the $5,000 lifetime max.
Home Healthcare
30% of negotiated fee after deductible,
90 visits/year
100% paid after deductible max. 90 visits/year (combined in/out of network)
30% of negotiated fee after deductible,
90 visits/year
Prescription Deductible
No separate deductible
No separate deductible
No separate deductible
Participating Pharmacies (30-day supply)
30% of negotiated drug fee after deductible
Plan pays 100% of negotiated drug fee after deductible
30% of negotiated drug fee after deductible
Self-Administered Injectable Drugs (excluding Insulin)
Retail (30-day supply)
Mail Order (60-day supply) Anthem Blue Cross NextRX Only
30% of negotiated drug fee after deductible
Plan pays 100% of negotiated drug fee after deductible
30% of negotiated drug fee after deductible
Mail Order (60-day supply) Anthem Blue Cross NextRX Only
Note: Some specialty drugs are available only through
Anthem Blue Cross’ Specialty Rx mail order program
30% of negotiated drug fee after deductible
Plan pays 100% of negotiated drug fee after deductible
30% of negotiated drug fee after deductible
Annual Deductible
No separate deductible, Out-of-Network benefits are included in the annual deductible
No separate deductible, Out-of-Network benefits are included in the annual deductible
No separate deductible, Out-of-Network benefits are included in the annual deductible
Annual Out-of-Pocket Maximum
No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.
$5,000 per individual*
$10,000 per family**
(Separate in-/out-of-network Out-of-Pocket Maximums)
No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.
Office Visits
Plan pays 50% of negotiated fee after deductible
Plan pays 70% of negotiated fee after deductible
Plan pays 50% of negotiated fee after deductible
Inpatient Hospital Services - Contracting Hospital
Plan pays 50% of negotiated fee, up to a max. of $540 per day after deductible
Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day
Plan pays 50% of negotiated fee, up to a max. of $540 per day after deductible
Mental and Nervous - Inpatient
Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible
Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day
Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible
Mental and Nervous - Outpatient
Plan pays 50% of negotiated fee after deductible
Plan pays 70% of negotiated fee after deductible, up to a maximum of $380 per day
Plan pays 50% of negotiated fee after deductible
Substance Abuse - Inpatient
Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible
Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day
Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible
Substance Abuse - Outpatient
Plan pays 50% of negotiated fee after deductible
Plan pays 70% of negotiated fee
after deductible, up to a maximum of $380 per day
Plan pays 50% of negotiated fee after deductible
Prescription Deductible
No separate deductible
No separate deductible
No separate deductible
Mail Order
Not covered
Not covered
Not covered
Retail Pharmacies (30-day supply)
Plan pays 50% of the negotiated drug fee after deductible. Member pays any excess charges.
Plan pays 70% of the negotiated drug fee after deductible. Member pays any excess charges.
Plan pays 50% of the negotiated drug fee after deductible. Member pays any excess charges.
Self-Administered Injectable Drugs
(excluding Insulin) Mail order not covered
Plan pays 70% of negotiated drug rate after deductible. Member pays any excess charge where self-injectable drug price exceeds negotiated drug rate
Plan pays 70% of negotiated drug
rate after deductible. Member pays
any excess charge where self-injectable drug price exceeds negotiated drug rate
Plan pays 70% of negotiated drug rate after deductible. Member pays any excess charge where self-injectable drug price exceeds negotiated drug rate
*Individual Coverage refers to a subscriber without covered dependents. Individual subscribers are subject to the Individual Deductible and Individual Out-of-Pocket Maximum.
**Family Coverage refers to a subscriber and covered dependents. Benefits will not be paid for any family member until the full Family Deductible is met. Lilkewise, the Family Out-of-Pocket Maximum will not be considered met for any family member until the full Family Out-of-Pocket Maximum is met.