Blue Cross Traditional PPO Medical Plan
Phone: 1-800-888-8288
Group no: 175028M007
ID no: Member ID (on ID card)
Website: www.anthem.com/ca/
| | PPO | Non-PPO |
| General Information |
| Annual Deductible | Individual: $250; Family: Maximum 3 Seperate Deductibles per Family |
| Annual Out-of-Pocket Maximum (does not include deductible) | $2000 per Member | $6000 per Member |
| Lifetime Maximum Benefit | $5,000,000 |
| |
| Medical Benefits |
| Doctor Office Visits | $15 copay Primary Care Physician | Covered at 70% |
| Routine Physical Exam (ages 7 and over) | $15 copay (Deductible Waived)
$250/yr maximum | Covered at 70% |
| Well-Baby Care (birth through age 6) | $15 copay (Deductible Waived) | Covered at 70% (Benefit limited to $20/exam) |
Prescription Drugs Copays:
Pharmacy (30-day Supply) | Generic: $10 copay
Formulary Brand: $20 copay
Non-Formulary: $40 copay | Generic: $10 copay + 50%
Formulary Brand: $20 copay + 50%
Non-Formulary: $40 copay + 50% |
| Prescription Drugs Copays:
Mail Order (90-day Supply) | 2 times pharmacy copay | 2 times pharmacy copay |
| Physical Therapy, Chiropractic Care | Covered at 80%; limited to 24 visits per calendar year | Covered at 60%; limited to 24 visits per calendar year |
| Diagnostic X-ray/Lab | Covered at 80% | Covered at 70% |
| |
| Hospital Benefits |
Room & Board
| Covered at 80% | Covered at 70%
(after $500 per admission deductible) |
| Surgeon's Fees | Covered at 80% | Covered at 70% |
| Maternity/Delivery | Covered at 80% | Covered at 70% |
| Emergency Room | Covered at 80% after $100 copay; (copay waived if admitted) | Covered at 80% after $100 copay; (copay waived if admitted) |
| Out-Patient Services | Covered at 80% | Covered at 70% |
| In-Patient Services | Covered at 80% | Covered at 70% |
| |
| Vision Benefits |
| Vision Benefit provided through Vision Service Plan | See VSP Summary for covered benefits |
Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form (PDF, 142 pages, 584K), 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.
