Phone: 1-800-888-8288
Group no: 175028
ID no: Member ID (on ID card)
Website: www.anthem.com/ca
Description: The high deductible PPO Medical Plan requires members to meet the deductible before the Plan will reimburse for any treatment, except routine and preventative care. The deductible is waived for routine and preventative care, and the treatment is covered 100%. For all other treatment, members must meet their deductible before the Plan pays for care. Participants may use the money saved in a Health Savings Account (HSA) to meet that deductible. The HSA allows members to designate a pre-tax dollar amount they wish to contribute to their HSA, and they may use that money to pay for medical care, prescriptions and other eligible medical expenses. The High Deductible PPO Plan includes traditional health coverage, similar to a typical health plan that protects members against large medical expenses after participants meet their deductible. See below for more info.
* Lumenos plans are wholly owned by Blue Cross.
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PPO |
Non-PPO |
| General Information |
| Annual Deductible |
Individual: $2500; Family: $5000 |
| Annual Out-of-Pocket Maximum (includes deductible) |
Individual: $3500; Family: $7,000
|
Individual: $7000; Family: $14,000
|
| Lifetime Maximum Benefit |
Unlimited |
| |
| Medical Benefits |
| Doctor Office Visits |
No copay
|
Covered at 70% |
Routine Physical Exam
|
No copay (Deductible Waived)
|
Covered at 70% |
Well-Baby Care
|
No copay (Deductible Waived) |
Covered at 70% |
| Adult Preventive Services |
After deductible is met: No copay |
After deductible is met: Covered at 70% |
Prescription Drugs Copays:
Pharmacy (30-day Supply)1 |
After deductible is met: prescriptions will be covered subject to a copay schedule of $10 Generic, $30 Brand, and $50 Non-Formulary.
Prescriptions that fall under Specialty Pharmacy will be covered at 70% after a $150 copay for a 30 day supply (currently a 90 day supply is available for specialty pharmacy).
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After deductible is met: Covered at 70% subject to a copay schedule of $10 Generic, $30 Brand, and $50 Non-Formulary.
Prescriptions that fall under Specialty Pharmacy will be covered at 70% after a $150 copay for a 30 day supply (currently a 90 day supply is available for specialty pharmacy).
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|
Prescription Drugs Copays:
Mail Order (90-day Supply)1
|
After deductible is met: No copay |
Not applicable
|
| Physical Therapy, Chiropractic Care |
After deductible is met: No copay; limited to 24 visits per calendar year |
After deductible is met: Covered at 70%; benefit limited to $25 per visit; per calendar year
|
| Diagnostic X-ray/Lab |
After deductible is met: No copay
|
After deductible is met: Covered at 70% |
| |
| Hospital Benefits |
Room & Board
|
After deductible is met: No copay |
After deductible is met: Covered at 70%
|
| Surgeon's Fees |
After deductible is met: No copay |
After deductible is met: Covered at 70% |
| Maternity/Delivery |
After deductible is met: No copay |
After deductible is met: Covered at 70% |
| Emergency Room |
After deductible is met: No copay |
After deductible is met: No copay
|
| Out-Patient Services |
After deductible is met: No copay |
After deductible is met: Covered at 70% |
| In-Patient Services |
After deductible is met: No copay |
After deductible is met: Covered at 70%
|
| |
| Vision Benefits |
| Vision Benefit provided through Vision Service Plan |
See VSP Summary for covered benefits
|
1Until the calendar year deductible is satisfied, the insured person pays the prescription drug covered expense, and not the copays listed.
Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form 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.
