(844) 967-1917
Anthem BlueCross

Gold 80 HMO

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    Plan Overview

    Medical Deductible
    • Individual: $0
    • Family: $0
    • Per Person: $0
    Prescription Drug Deductible
    • Individual: $0
    • Family: $0
    • Per Person: $0
    Combined Medical and Drug Out of Pocket Maximum
    • Individual: $8,200
    • Family: $16,400
    • Per Person: $8,200

    Office Visit

    Primary Doctor
    • CoPay: $35.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Specialist
    • CoPay: $65.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

    Prescription Drug Information

    Preferred Brand Drugs
    • CoPay: $55.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Non Preferred Brand Drugs
    • CoPay: $80.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Generic Drugs
    • CoPay: $15.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Specialty Drugs
    • CoPay: Not Applicable
    • CoInsurance: 20.00%
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

    Inpatient Coverage

    Hospital Services
    • CoPay: $600.00 Copay per Day
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
    Inpatient Services
    • CoPay: No Charge
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.

    Emergency and Urgent Care

    Emergency Room
    • CoPay: $350.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Urgent Care Facility
    • CoPay: $35.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

    Maternity

    Labor and Delivery Hospital Stay
    • CoPay: $600.00
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Pre and Postnatal Office Visit
    • CoPay: No Charge
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

    Vision

    Routine Eye Exams For Children
    • CoPay: No Charge
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Limit Quantity: 1
    • Limit Unit : Visit(s) per Year
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

    Major Dental Care

    Routine Dental Checkups for Children
    • CoPay: No Charge
    • CoInsurance: Not Applicable
    • Covered: Covered
    • Limit Quantity: 1
    • Limit Unit : Visit(s) per 6 Months
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Routine Dental Checkups for Adults
    • Covered: Not Covered
    Basic Dental Care - Adult
    • Covered: Not Covered
    Basic Dental Care - Child
    • CoPay: Not Applicable
    • CoInsurance: 20.00%
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Major Dental Care - Adult
    • Covered: Not Covered
    Major Dental Care - Child
    • CoPay: Not Applicable
    • CoInsurance: 50.00%
    • Covered: Covered
    • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
    Health care service plans provided by Anthem Blue Cross. Insurance policies provided by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.®The Blue Cross name and symbol are registered marks of the Blue Cross Association.
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