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Annual Deductible : |
$2,000 per person/out-of-network doubles |
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Coinsurance : |
You pay 20% in-network/40% out-of-network |
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Annual Out-of-Pocket Maximum (includes deductible) : |
$3,000 per person, doubles out-of-network |
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Lifetime Maximum : |
$2million per person |
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Office Visits : |
$25 Copay |
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Professional Service Includes X-ray and lab charges : |
You pay 20% |
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Emergency Care : |
You pay 20% |
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Ambulance : |
You pay 40%, $350 maximum for ground services, $5,000 maximum for air services |
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Hospital Inpatient Services : |
You pay 20% |
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Outpatient Services : |
You pay 20% |
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Preventive Care- Children : |
You pay 20%, deductible waived (through age 12) |
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Preventive Care- Adult : |
You pay $25, deductible waived limited to the following services: $75 maximum for routine pap smear |
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Vision Care : |
Anthem Vision Coverage: You pay: $25 for exam, $25 for lenses and frames. |
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Prescription Drug Benefits : |
You pay $15 Generic You pay $40 Brand Formulary You pay $60 Non-formulary |
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Maternity : |
Not Covered |
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Additional Services : |
Anthem Vision Coverage: You pay: $25 for exam, $25 for lenses and frames. $500 additional accident benefits per member per accident in allowed charges. A second surgical opinion maybe obtained if desired. |
