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Summary of Benefits Protect 10

Non-Grandfathered Plans Effective January 1, 2012

 
Provisions In-Network Out-of-Network (1)
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

 
Out-of-Pocket Maximum (annual)

 

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

 

 

$5,000 per member

 
Lifetime Maximum Benefit

 

No lifetime maximum
$2,000,000 calendar year maximum

 

 

Inpatient & Outpatient Hospital Services

 

 

10% of negotiated fee

 

 

Plan pays 70% of UCR
up to $540 per day

 


Emergency Room Deductible

 

 

$100 (2)

 

 

Office Visits

 

 

$10 copay per visit.

 

 

Plan pays 70% of UCR

 

 

Physical Therapy, Speech Therapy
(including chiropractic care)
There is a maximum of 25 visits per year Maximum limit includes visits to both in-network and out-of-network providers

 

 

$10 copay, plus 10% of the
remaining negotiated fee

 

 

Plan pays 70% of UCR,
up to $40 per visit

 

 

Preventive (ages 7 and up)
1 Physical per year

 

 

100% plan paid,

not subject to the deductible

 

 

Plan pays up to $250

Well-Woman Care

1 visit per year

100% plan paid,

not subject to the deductible

 Plan pays 70% of UCR

 

Well-Baby Care (ages 0–6)

 

 

100% plan paid,

not subject to the deductible

 

Plan pays 70% of UCR
Prescription Drugs

 

Prescription Drugs Annual Deductible
(combines in/out-of-network charges)
Note: Some Specialty Drugs are only available
through Anthem Blue Cross CuraScript mail order program

 

 

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

Prescription Drugs - Retail (30-day supply)

 

Generic

Brand-Formulary

Brand-Non-Formulary

 

 

 

$10

$25

$45

 

Retail in-network copay plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount.

Prescription Drugs - Mail Order (60-day supply)

 

Generic

Brand-Formulary

Brand-Non-Formulary

 

 

 

 

$10

$25

$45

 

Not covered

 

 

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

 

 


30% of prescription drug maximum allowed amount

 


Not covered

 

 

Mental Health and Substance Abuse

 
  In-Network Out-of-Network Benefits (6)

Inpatient

 

 

10% of negotiated fee

 

Plan pays 70% of UCR, up to $540 per day

 

Office Visits/Therapy Sessions

 

$10 copay

 

Plan pays 70% of UCR, up to $540 per day

 

Outpatient

 

 

10% of negotiated fee

 

 

Plan pays 70% of UCR, up to $540 per day

 

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. You pay any excess charges.
2. Waived if admitted
3. Copays do not apply toward satisfaction of the annual deductible or out-of-pocket maximum
4. Rx deductible is not integrated with the medical deductible
5. Customary & Reasonable
6. Member is responsible for all charges in excess of plan payments.

This chart is not a contract. Please refer to each plan’s Medical Plan Document and Disclosure Form or Certificate.
Benefits listed are per-member costs, subject to deductibles and copayments unless otherwise stated.