Anthem Blue Cross Basic PPO Plan:

Anthem Blue Cross currently offers many different insurance plans to suit your needs. If you are looking for a PPO type plan, there are three main options. The Basic PPO plan offers a co-insurance type of coverage and can assist you in meeting your health care needs, with the greater freedom of choosing your own provider.

Let’s take a look at what this plan has to offer. Your individual premiums may vary, based on several different factors. However, this should give you an idea of the amount of coverage you can enjoy under this plan.

Lifetime Maximum - The Basic PPO plan from Anthem Blue Cross offers a lifetime maximum of $5,000,000 of coverage per member. This counts towards both participating and non-participating providers.

Annual Out of Pocket Maximum - The amount that you will spend out-of-pocket for this plan is $3500 for both participating and non-participating providers combined.

Annual Deductible - The annual deductible for this plan is $1000 for all covered benefits for participating and non-participating providers.

Office Visits - Office visits are not covered under this plan until you have reached your out-of-pocket maximum, whether you visit a participating or non-participating provider. After your out-of-pocket expenses amount has been met, then 100% of the negotiated fee is covered for both participating and non-participating providers.

Professional Services - These services include other types of office visits, anesthesia, surgeon fees, X-rays and lab costs. For participating providers, you will to pay for 20% of the negotiated fee for services that are incurred in a hospital. Office visits are not covered until you have reached your annual out-of-pocket maximum amount. At this point, 100% of these visits will be covered. For non-participating providers, your costs are 50% of the limited fee schedule as well as 100% of any excess over this amount.

Hospital Inpatient and Outpatient Care - For participating providers, you will have to pay 20% of the negotiated fee. Care from non-participating providers requires you to pay for all services, minus $650 per day for inpatient care or $380 per day for outpatient care.

Hospice Care - There is a $10,000 lifetime maximum coverage for care at a participating or non-participating hospice with this plan.

Emergency Services - If you require emergency services and visit a participating physician, you will need to pay for 20% of the negotiated fee for these services. Emergency care received from a non-participating provider requires the following fees: 20% of the “customary and reasonable” amount during the first 48 hours of your treatment, as well as 100% of any excess charges. After this 48 hours has elapsed, you will then be required to pay for all charges, minus $650 per day for services that are covered by this plan.

Maternity - Maternity coverage is not provided with this plan. You may be able to add-on a benefit rider if you need this type of coverage. Check with your insurance representative to see if this is available for you.

Preventative Care - For preventative care that is received at HealthyCheck centers there is a $25 or $75 co-pay. This is required for PSA and cancer screenings, routine mammograms and basic screenings. In addition to the co-pay, you will need to pay 20% of the negotiated fee, but your plan deductible is waived.

For care received outside of the state of California, you will be charged 50% of the “customary and reasonable” amount up to a maximum of $250 per year. If your doctor has ordered a routine mammogram, PSA or cancer screening, you will then need to pay 50% of the “customary and reasonable” amount as well as 100% of any excess charges.

Ambulance - If you require an ambulance, this plan requires a 20% payment of the negotiated fee, with a $750 maximum per trip for participating providers. If an ambulance service is not a participating provider, this moves up tot 50% of the “customary and reasonable” fee, plus 100% of any excess charges.

Physical and Occupational Therapy and Acupuncture or Acupressure Therapy - This coverage is not offered by the Basic PPO plan. However, you may be able to add-on benefit riders for these areas of coverage if you require them.

Prescription Drug Benefits - This plan does not offer any prescription drug benefit. If you are unable to add-on a benefit rider, you may be able to find a dental discount plan in your area that will assist you in paying for your prescriptions.

Please keep in mind that charges incurred by non-participating providers that are over the negotiated fee will not be paid by this plan. The amount that you spend on these services that are not covered do not count towards your annual out-of-pocket maximum. You will also need to pay $500 admission charge at participating hospitals if you have been admitted for surgery or an infusion therapy. However, if you have a medical emergency, you will not be required to pay this admission charge.

If you visit an emergency room and are not admitted to the hospital, there is a $30 co-pay for each visit. This fee is waived if you are admitted.

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