Anthem Blue Cross and Blue Shield

Anthem Gold X Clear Choice Tiered 2500

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    Plan Overview

    Medical Deductible
    • 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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    We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

    Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

    HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

    This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

    HMPLAN48396ME0710078ACA1

    © 2024 HealthMarkets Insurance Agency. All rights reserved.

    We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

    Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

    HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

    This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

    HMPLAN48396ME0710078ACA1

    © 2024 HealthMarkets Insurance Agency. All rights reserved.

    We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

    Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

    HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

    This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

    HMPLAN48396ME0710078ACA1