Anthem Blue Cross Small Group High Deductible EPO Plan:

The last plan available to your employees’ under the small group health plans offered by Anthem Blue Cross is the High Deductible EPO plan. If your employees are looking for a high deductible plan, this particular plan offers a high amount of coverage. The majority of services covered under this plan must be provided by an in-network physician or hospital. In some cases, such as inpatient care or outpatient services, it will provide some coverage if there is an emergency, but the deductible must be met before this coverage will take effect. The lifetime maximum benefit for this plan is $5,000,000.

Annual Deductible - If your employee is the only one covered by this plan the deductible is $2000. If they have one or more dependents, this goes up to $4000 per year.

Annual Out-of-Pocket Maximum - The most your employees’ will pay for their health care needs under this plan is $3100 per year, if they are the only one covered by the policy. For a family plan, this moves up to $5700 per year.

Office Visits - Once your employees’ reach their deductible, all office visits require a 20% co-insurance payment of the negotiated fee. Professional services, which may include maternity care, lab tests, x-rays or other services will also require a 20% payment after the deductible has been met.

Hospital Inpatient Care - After a Preservice review has been completed, this plan requires a 20% co-insurance payment once the deductible has been reached. In the event that your employee has an emergency, some level of coverage is provided if they need to visit a non-participating provider. This coverage is subject to the annual deductible. Professional services received while in the hospital, such as diagnostic lab tests, anesthesia, or surgeon fees are also subject to this pay schedule.

Hospital Outpatient Care - Once again, a Preservice review is required before coverage will take effect. The costs are 20% of the negotiated fee, after the deductible has been met. As with inpatient care, if it is an emergency, some coverage may be provided if an employee visits an non-participating provider for their care.

Prescription Drugs - Prescriptions purchased at a non-participating pharmacy are not covered by this plan. Otherwise, there is a $10 co-pay for generic prescriptions, limited to a 30-day supply if purchased in person or a 60-day supply if purchased online or through the mail. If a prescription is considered brand name, the co-pay goes up to $25, once the annual deductible has been reached. If your employee requires infertility drugs, there is a $1500 lifetime maximum limit for these prescriptions under this plan.

Other care - Emergency care, ambulance costs, care received at a skilled nursing facility, home health care or physical or occupational therapy will require a 20% co-insurance payment after the annual deductible is met, as long as the services are received from a participating hospital, facility or physician. In the event that there is an emergency, there is an emergency care benefit and an ambulance benefit for non-participating providers. This requires a payment of 20% of the customary and reasonable fee, as well as 100% of any excess charges. These services are also subject to the annual deductible.

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