Benefit Explanation: 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 mobile app, website, or Anthem-enabled devices
Specialist
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 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 mobile app, website, or Anthem-enabled devices
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day retail supply
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day retail supply
Generic Drugs
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day retail supply
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Limited to a 30 day supply
Inpatient Coverage
Hospital Services
CoPay: $500.00 Copay per Stay after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $500.00 Copay after deductible
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copayment (if applicable) is waived if admitted.
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share is driven by provider/setting.
Maternity
Labor and Delivery Hospital Stay
CoPay: $500.00 Copay after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section