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Medical
Medical Benefits
Anthem Blue Cross Traditional HMO
Anthem Blue Cross Select HMO
Calendar Year Deductible
N/A
Maximum Calendar Year Co-pay (excl. pharmacy)
$1,500 individual / $3,000 family
Hospitalization
(including Mental Health and Substance Abuse)
Deductible
Inpatient/Outpatient
N/A
No charge
Emergency Room Deductible
Emergency Room Co-pay
(For inpatient or for observation as an outpatient)
Non Emergency Co-pay
(For inpatient or for observation as an outpatient)
N/A
$50 (waived if admitted)
$50 (waived if admitted)
Physician Services
(including Mental Health and Substance Abuse)
Office Visit Copay
Inpatient
Outpatient
$15 / visit
No Charge
$15
Diagnostic X-Ray / Lab
No charge
Prescription Rx: Retail
(up to a 30 day supply only)
Generic Rx / Brand Name / Non-formulary
$5 / $20 / $50
Prescription Rx: Retail Maintenance Medications
(for medications taken for 60 days or more not to exceed
30 day supply)
Generic Rx / Brand Name / Non-formulary
$10 / $40 / $100
Prescription Rx: Mail Order Pharmacy
(not to exceed 90 day supply for maintenance drugs)
Generic Rx / Brand Name / Non-formulary
$10 / $40 / $100
Maximum co-payment/person per calendar year
$1,000
Durable Medical Equipment
No charge
Infertility Testing/Treatment
50% of covered charges
Occupational/Physical/Speech Therapy
No charge (inpatient) / $15 (outpatient)
Diabetes Services
Glucose Monitoring
Self-Management Training
No charge
$15
Acupuncture / Chiropractic
(Limited to a combined 20 visits per calendar year)
$15 / visit