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Non-Grandfathered Plans Effective January 1, 2011

In-Network Benefits
Protect 10 Protect 15 Protect 25 Protect 35 Protect 45

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

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

$250 per member in/out-of-network
$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 in/out-of-network
$1,000 family aggregate
Generally, all medical benefits are covered only after the plan’s deductible has been met

$0

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

$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

Hospital Admission Deductible

(Includes Mental & Nervous and Substance Abuse Admissions)

NA

NA

NA

NA

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

Inpatient & Outpatient Hospital Services

10% of negotiated fee

20% of negotiated fee

30% of negotiated fee

40% of negotiated fee

50% of negotiated fee

Emergency Room Deductible

$1003

$1003

$1003

$1003

$1003

Office Visits

$10 copay per visit

$15 copay per visit. First 6 in-network visits (combined with in-network mental & nervous and substance abuse outpatient visits) per calendar year are not subject to the deductible.

$25 copay per visit. First 6 in-network visits (combined with in-network mental & nervous and substance abuse outpatient visits) per calendar year are not subject to the deductible.

$35 copay per visit. First 6 in-network visits (combined with in-network mental & nervous and substance abuse outpatient visits) per calendar year are not subject to the deductible.

$45 copay per visit

Preventive (ages 7 and up)
1 Physical per year
Deductibles do not apply

100% plan paid

100% plan paid

100% plan paid

100% plan paid

100% plan paid

Well-Baby Care (ages 0-6
Well Woman Care (1 visit per year)
Deductibles do not apply

100% plan paid

100% plan paid

100% plan paid

100% plan paid

100% plan paid

Prescription Drugs Annual Deductible

Note:Prescription drug deductible is separate from annual medical deductible

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

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

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

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

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

$150 per person
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 Anthem Blue Cross CuraScript Pharmacy program.CuraScript dispenses biotech drugs for these conditions and will schedule drug delivery either to the member's home or to a physician's practice.

Prescription Drugs - Retail
(30 day supply)

 

 

 

 

 

Generic

$10

$10

$10

$10

$10

Brand-Formulary

$25

$25

$25

$25

$25

Brand - Non-Formulary

$45

$45

$45

$45

$45

Prescription Drugs - Mail Order
(60 day supply)

 

 

 

 

 

Generic

$10

$10

$10

$10

$10

Brand -Formulary

$25

$25

$25

$25

$25

Brand - Non-Formulary

$45

$45

$45

$45

$45

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


30% prescription drug maximum allowed amount


30% prescription drug maximum allowed amount


30% prescription drug maximum allowed amount


30% prescription drug maximum allowed amount


30% 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

50% of negotiated fee

Mental & Nervous/ Substance Abuse
Outpatient

10% of negotiated fee

20% of negotiated fee

30% 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

$45 copay



Note: Where a maximum number of visits per year/per day is indicated, it includes both in-network and out-of-network services.

1. Payments to out-of-network providers are based on negotiated fees (or UCR for the Protect 10 Plan). You pay any charges in excess of these fees.
2. UCR = Usual, Customary and Reasonable
3. Waived if admitted
4. Copays do not apply toward satisfaction of the annual deductible or out-of-pocket maximum



This chart is not a contract. Please refer to each plan's Medical Plan Document and Disclosure Form or Certificate.

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