Non-Grandfathered Plans Effective January 1, 2012
In-Network Benefits
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**
$3,500 per member*
$7,000 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**
$5,500 per member*
$11,000 per family**
Lifetime Maximum Benefit
None
($2,000,000 cal. year max.)
None
($2,000,000 cal. year max.)
None
($2,000,000 cal. year max.)
None
($2,000,000 cal. year max.)
Office Visits
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% of negotiated fee after deductible
Other Professional Services
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% of negotiated fee after deductible
Emergency Care
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% 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
20% 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
20% of negotiated fee after deductible
Other Professional Services
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% of negotiated fee after deductible
Well Woman Care
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Well Baby Care
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.
Preventive Care
(Ages 7 & Up)
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Not subject to the deductible, 100% plan paid. 1 visit/year
Mental and Nervous/Substance Abuse - Inpatient
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
30% of negotiated fee after deductible
Mental and Nervous/Substance Abuse - Outpatient
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% 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
20% 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
20% of negotiated fee after deductible.
Plan pays up to $60/visit after deductible,
max. 12 visits/year
Durable Medical Equipment
30% of negotiated fee after deductible
100% paid after deductible
30% of negotiated fee after deductible
20% 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
20% 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.
20% 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
20% of negotiated fee after deductible,
90 visits/year
Prescription Deductible
No separate deductible
No separate deductible
No separate deductible
No separate deductible
Participating Pharmacies (30-day supply)
30% of negotiated drug rate after deductible
Plan pays 100% of negotiated drug rate after deductible
30% of negotiated drug rate after deductible
20% of negotiated drug rate after deductible
Self-Administered Injectable Drugs (excluding Insulin)
Retail (30-day supply)
Mail Order (60-day supply) Anthem Blue Cross Express Scripts Only
30% of negotiated drug rate after deductible
Plan pays 100% of negotiated drug rate after deductible
30% of negotiated drug rate after deductible
30% of negotiated drug rate after deductible
Mail Order (60-day supply) Anthem Blue Cross Express Scripts Only
Note: Some specialty drugs are available only through
Anthem Blue Cross’s CuraScript mail order program
30% of negotiated drug rate after deductible
Plan pays 100% of negotiated drug rate after deductible
30% of negotiated drug rate after deductible
20% of negotiated drug rate 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
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.
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 allowable fee after deductible
Plan pays 70% of allowable fee after deductible
Plan pays 50% of allowable fee after deductible
Plan pays 50% of allowable fee after deductible
Inpatient Hospital Services - Contracting Hospital
Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible
Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day
Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible
Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible
Mental and Nervous/Substance Abuse - Inpatient
Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible
Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day
Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible
Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible
Mental and Nervous/Substance Abuse - Outpatient
Plan pays 50% of allowable fee after deductible
Plan pays 70% of allowable fee after deductible, up to a maximum of $380 per day
Plan pays 50% of allowable fee after deductible
Plan pays 50% of allowable fee after deductible
Prescription Deductible
No separate deductible
No separate deductible
No separate deductible
No separate deductible
Mail Order
Not covered
Not covered
Not covered
Not covered
Retail Pharmacies (30-day supply)
Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.
Plan pays 70% of the allowable drug fee after deductible. Member pays any excess charges.
Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.
Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.
Self-Administered Injectable Drugs
(excluding Insulin)
Not covered
Not covered
Not covered
Not covered
*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. Likewise, 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.
Prescription drug benefits are provided through Medco. Specialty drugs are provided through Accredo.