Anthem Blue Cross Life and Health PPO Share Plan:

If you need a PPO plan for your health care needs, Anthem Blue Cross offers several different options. We will first look at the Life and Health PPO Share Plan and explain what type of benefits you can expect. Your individual premiums for this plan may vary on your eligibility and other factors, but this should give you an idea of the kind of coverage that you can expect. A share plan implies a level of co-insurance, which will require you to pay for some part of your medical care. If you are looking for a plan that does not require co-insurance, Anthem Blue Cross offers several alternatives.

Annual Deductible - The annual deductible for this plan is $5000. This includes medical expenses from both participating and non-participating providers.

Annual Out of Pocket Maximum - The annual amount that you will have to spend out of pocket with this plan is $7500. This includes your deductible amount, and is combined between participating and non-participating providers.

Office Visits - This plan charges 30% for regular medical services with participating providers, or 40% for well-child visits. The deductible is waived for these visits. With non-participating providers, the co-insurance amount is 50% of the negotiated fee.

Professional Services - For visits not covered or classified as “office visits", x-ray, lab fees, anesthesia or surgeon fees, your costs for treatment by a participating provider will be 30% of the negotiated fee. Your deductible amount is not waived for these services. With a non-participating provider, this amount is 50% of the negotiated fee, and 100% of any excess.

Inpatient Coverage - Hospitalization costs are 30% of the negotiated fee with a participating provider. A non-participating provider will result in coverage of all charges except, $650 per day for inpatient care.

Outpatient Coverage - If your care is considered on an out-patient basis, your fees will be 30% for participating providers. Your costs for treatment by a non-participating provider are all charges except $380 per day.

Hospice Care - This plan offers a $10,000 maximum benefit for participating providers, and non-participating providers combined.

Emergency Services - If you need emergency treatment, under this plan, you would be required to pay 30 % of the negotiated fee with a participating provider. For non-participating providers, you will need to provide 30% of the “customary and reasonable" fee for the first 48 hours of treatment as well as 100% of excess. After this first 48 hours, you pay for all services and charges, except for $650 per day for covered services.

Preventative Care - Anthem Blue Cross offers a Health Check preventative care program. Under this program you will pay $25 or $75 in a co-pay for routine mammograms, basic screenings, PSA or cancer screening that have been ordered by your physician as well as 30% of the negotiated fee, or 40% of the negotiated fee for well-child checks. Your deductible is waived for these services. For a non-participating provider, you will need to pay 50% of the negotiated fee for PSA and cancer screenings, or routine mammograms, plus 100% of any excess charges.

Ambulance - If you require an ambulance to transport you to a hospital or a clinic, your costs will be 30% for a participating provider. For a non-participating provider, this fee goes up to 50% of the “customary and reasonable" charges, as well as 100% of any excess fees.

Physical or Occupational Therapy or Chiropractic Services - With a participating provider or non-participating, you are allowed up to 12 visits per calendar year combined. For a participating provider, you will need to pay 30% of the negotiated fee for these services. With a non-participating provider, this moves up to all charges, minus $25 of coverage for each visit.

Maternity - If you need maternity care during your pregnancy, you will need to pay 30% for services from participating providers and 50% of the negotiated fee plus 100% of the excess for a non-participating provider.

Acupuncture or Acupressure Therapy - This Anthem Blue Cross plan does provide some coverage for alternative medical treatments. If your doctor orders acupuncture or acupressure treatments, you will need to pay for all of the charges, minus $25, regardless if the therapist is a participating or non-participating provider. You are allowed up to 24 visits per year, with both participating and non-participating providers combined.

Prescription Benefits - This plan covers retail and mail order prescriptions, up to a 30-day supply. With a participating provider, you will have to pay $10 for a generic prescription or $35 for a brand, as well as a $750 brand deductible. This deductible does not count towards your out-of-pocket maximum amount. If you need prescriptions that are considered self-administered injectables, your cost is 30% of the negotiated fee. This does not include insulin.

For any non-formulary prescriptions, a generic prescription will cost 50% of the negotiated fee. A brand prescription that is non-formulary will require you to provide 100% of the cost. If you are unsure if your prescription is considered formulary or non-formulary, you ask your insurance representative for a copy of the formulary list. This will assist you in determining which prescriptions will enjoy greater coverage and which will not.

For a non-participating provider, your cost is 50% for a generic drug, and 50% for a brand drug, as long as it is purchased in California. There is also a $750 brand deductible with this plan.

It is important to note that charges from non-participating providers will not be covered unless delineated above. In addition, these charges will not count towards your out-of-pocket maximum under this plan. Hospital inpatient care at a participating hospital will require an additional $500 admission charge if you require surgery or infusion therapy. However, this fee does not apply for Ambulatory Surgical Centers, or in the event of a medical emergency. Emergency room visits are covered as mentioned above, but will also incur a $100 co-pay for each visit under this plan.

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