Anthem Clear Choice Gold X PPO 2500
Anthem Blue Cross and Blue Shield
Plan overview
Medical deductible
Individual: $2500
Family: $5000
Per Person: $2500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $6000
Family: $12000
Per Person: $6000
Office visit
Primary Doctor
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: The first visit when you obtain primary care services during an office visit, virtual visit or in a retail health clinic is covered in full - not subject to deductible. For additional primary care office visits, virtual visits and retail health clinic visits, you pay a copay per visit - not subject to deductible. Services performed during the office visit are covered at 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 mobile 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 mobile application or website.
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
Benefit Explanation: 30 day supply only for retail or home delivery.
Inpatient coverage
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 and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
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 Anthem’s maximum allowed amount if balance billed by the provider. Cost share is driven by provider/setting.
Maternity
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
Vision
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.
Major dental care
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
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).