Anthem Blue Cross and Blue Shield

Anthem Gold X Clear Choice Tiered 2500

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Medical Deductible	Individual: $2,500 Family: $5,000 Per Person: $2,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,000 Family: $12,000 Per Person: $6,000

Primary Doctor

CoPay: $25.00
CoInsurance: No Charge
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 and not subject to deductible. For additional office visits, you paya copay per visit which is not subject to deductible. Services performed during the office visit are covered at deductible and coinsurance (for example labs, x-rays, etc.). You many 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: $50.00
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: Cost share shown is for a 30 day supply. 90 day supply for home delivery is also available.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 90 day supply for home delivery is also available.
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 90 day supply for home delivery is also available.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: 30 day supply only for retail or home delivery

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	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Emergency Room copay, if any, is waived if directly admitted to the hospital.
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. 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

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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