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Medical / In-Network Only
This comparison chart shows a brief summary of the medical benefits available.
Anthem Blue Cross
80-E PPO 1 Plan
Anthem Blue Cross
80-G PPO 2 Plan
Annual Deductible
$300/Individual
$600/Family
$500/Individual
$1,000/Family
Annual Out-of-Pocket Max
$1,000/Individual
$3,000/Family
$2,000/Individual
$4,000/Family
Lifetime Max
Unlimited
Unlimited
Office Visit
Primary Provider
$20 (deductible waved)
$30 (deductible waved)
Specialist
$20 (deductible waved)
$30 (deductible waved)
Preventive Services
Plan pays 100%
Plan pays 100%
Chiropractic Care
Plan pays 80% of charges
Plan pays 80% of charges (limits apply)
Acupuncture Care
(limited to
12 visits per calendar year)
Plan pays 80% (limited to $50 / visit)
Plan pays 80% (limited to $50 / visit)
Lab and X-ray
Plan pays 80% of charges
Plan pays 80% of charges
Inpatient Hospitalization
Plan pays 80% of charges
Plan pays 80% of charges
Outpatient Surgery
Plan pays 80% of charges
Plan pays 80% of charges
Urgent Care
$20 (deductible waved)
$30
Emergency Room
(copay
waived if admitted)
$100 copay then plan pays 80% of charges
$100 copay then plan pays 80% of charges
Ambulance
$100 copay then plan pays 80% of charges
$100 copay then plan pays 80% of charges