Blue Cross HMO Medical Plan
Phone: 1-800-227-3771
Group no: 175028H001
ID no: Member ID (on ID card)
Website: www.anthem.com/ca
| Benefit | Coverage/Copay |
| Deductible | None |
| Inpatient Hospital | 100% coverage |
| Physician Office Visits | $15 copay |
| Routine Physical Exams | $15 copay |
| Routine GYN Exams | $15 copay |
| Maternity Care Office Visits | $15 copay |
| Well-Baby Care | $15 copay |
| Prescription Drugs | $10 copay generic;$20 copay for non-generic formulary brand;$40 copay for non-generic non-formulary brand |
| Emergency Room (waived if admitted) | $50 copay |
| Chiropractic | $15 copay; 20 visits per year (combined with acupuncture care) |
Mental Health (Outpatient)*
| $20 copay; 20 visits per 12 months |
| Mental Health (Intpatient)* | 100% coverage; 30 days per year |
| Vision Benefit provided through Vision Service Plan | See VSP Summary for covered benefits |
* Non-severe only. Severe mental health is covered as any other illness. SCU provides additional mental health benefits through its Employee Assistance Program (EAP) and Mental Health Benefits Program with United Behavioral Health (UBH).
This is a summary of the benefits provided. Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form (157 pages, 650K), which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. Under all circumstances, policy form and wording take precedence over information contained in this summary.
