Anthem Blue Cross and Blue Shield

Anthem Clear Choice Silver X PPO 3500

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Combined Medical and Drug Deductible	Individual: $3,500 Family: $7000 Per Person: $3500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500 Family: $17000 Per Person: $8500

Primary Doctor

CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: The first visit when you obtain primary care services during an office visit, online or in a retail health clinic is covered in full - not subject to deductible. For additional primary care office visits and retail health clinic visits, you pay a copay per visit - not subject to deductible. Online office visits only are always covered in full. Services performed during the office visit are covered at deductible and coinsurance (for example labs, x-rays, etc.). You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our virtual application or website.

Specialist

CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: When there is a copay for the office visit, the copay is for the office visit only. All other services provided during the visit are subject to deductible and coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our virtual application or website.

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Members can choose to receive a 90-day supply at participating retail pharmacies for certain maintenance drugs. When a 90 day supply is purchased at retail, if there is a copay, the copay is three times the standard retail copayment. Visit Anthem.com for additional information.
Non Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Members can choose to receive a 90-day supply at participating retail pharmacies for certain maintenance drugs. When a 90 day supply is purchased at retail if there is a copay, the copay is three times the standard retail copayment. Visit Anthem.com for additional information.
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Members can choose to receive a 90-day supply at participating retail pharmacies for certain maintenance drugs. When a 90 day supply is purchased at retail, if there is a copay, the copay is three times the standard retail copayment. Visit Anthem.com for additional information.
Specialty Drugs	CoPay: $250.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share will vary based on network pharmacy utilized. Cost share will vary based on network pharmacy utilized. Visit Anthem.com for additional information.

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency Room

Urgent Care Facility

CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: When there is a copay, the copay is for the office visit only. All other services provided during the visit are subject to deductible and coinsurance. Services performed outside the office setting are covered at deductible and coinsurance. Office based urgent care services received from an out-of-network provider are covered; however, the member may be responsible for charges in excess of Anthems maximum allowed amount if balance billed by the provider. Cost share is driven by provider/setting.

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Maternity care may include tests and services described elsewhere within the SBC (i.e. ultrasound).
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Eye Exams are covered once per benefit period. Limit is combined for in network and out of network. Limited reimbursement applies for out of network exams up to the maximum allowable.

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: Limited to 2 visits per year.
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered