Anthem Blue Cross and Blue Shield

Anthem Catastrophic X 8700

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Combined Medical and Drug Deductible	Individual: $8,700 Family: $17,400 Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Primary Doctor

CoPay: $50.00 Copay with deductible
CoInsurance: No Charge after deductible
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, visits 2 and 3 are covered at a copay. All additional visits are subject to deductible/coinsurance. 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.

Specialist

Preferred Brand Drugs	CoPay: No Charge after deductible 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: No Charge after deductible 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.
Generic Drugs	CoPay: No Charge after deductible 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: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply only for retail or home delivery

Hospital Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Emergency Room	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Emergency Room copay, if any, is waived if directly admitted to the hospital.
Urgent Care Facility	CoPay: No Charge after deductible 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: No Charge after deductible CoInsurance: Not Applicable 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: No Charge after deductible CoInsurance: Not Applicable 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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