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;
100% coverage after $250 copay - new for 2010
|
| Physician Office Visits |
$15 copay;
$20 copay - new for 2010
|
| Routine Physical Exams |
$15 copay;
$20 copay - new for 2010 |
| Routine GYN Exams |
$15 copay;
$20 copay - new for 2010 |
| Maternity Care Office Visits |
$15 copay;
$20 copay - new for 2010 |
| Well-Baby Care |
$15 copay;
$20 copay - new for 2010 |
| Prescription Drugs |
$10 copay generic;$20 copay for non-generic formulary brand;$40 copay for non-generic non-formulary brand;
$10 copay generic;$25 copay for non-generic formulary brand;$50 copay for non-generic non-formulary brand - new for 2010
|
| Emergency Room (waived if admitted) |
$50 copay;
$100 copay - new for 2010 |
| Chiropractic |
$15 copay; 20 visits per year (combined with acupuncture care);
$20 copay, no maximum - new for 2010 |
Mental Health (Outpatient)*
|
$20 copay; 20 visits per 12 months;
$20 copay, no maximum - new for 2010 |
| Mental Health (Intpatient)* |
100% coverage; 30 days per year;
100% coverage after $250 copay - new for 2010
|
| 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 (PDF, 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.
For 2010: Blue Cross HMO Summary of Benefits | Blue Cross Care and Acupuncture Rider Plan
