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Anthem Blue Cross and Blue Shield

Anthem Gold X Clear Choice Tiered 2500

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    Plan Overview

    Medical Deductable
    • 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

    Office Visit

    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.

    Prescription Drug Information

    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

    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
    • 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.

    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: Once every calendar year.

    Major Dental Care

    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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