Anthem Blue Cross Small Group Advantage PPO $25 Co-Pay Plan:

If your employees’ are searching for a lower deductible PPO type plan, this particular plan offered by Anthem Blue Cross may suit their needs. The out-of-pocket maximum is lower than many of the other plans offered by Anthem Blue Cross but the lifetime maximum of $5,000,000 is the same. This plan offers a cheaper alternative to expensive co-pays and a stair-step method of calculating costs.

Annual Deductible - The annual deductible for this plan is $250. This is extremely low for a PPO type plan and can offer many employees the option of more comprehensive coverage.

Annual Out-of-Pocket Maximum - The most your employees’ will pay under this plan each year is $3600 just as long as they visit a physician or hospital that is part of the Anthem Blue Cross network. The annual out-of-pocket maximum of $10,000 for non-participating physicians and hospitals is quite a bit higher, but does offer 100% coverage once it has been reached.

Office Visits - There are currently 12 office visits allotted to each plan member per year. Your employees can expect to pay a $25 co-pay for visits to participating physicians under this plan. After they reach 12 visits, the fee is calculated in the following manner: 30% of any charges up to $900 and then 10% for charges from $901 to $3600. This method of calculation is also used for professional services from participating plan physicians, but these services are subject to the deductible, unlike regular office visits. If your employees need to see a physician that is not in the network, they will need to pay for 50% of their services, plus 100% of any costs that are not covered by the plan, after the deductible has been met.

Hospital Inpatient Coverage - There is a Preservice review required for inpatient coverage. Once this is approved, care received at a participating hospital will cost your employees’ 30% of the charges up to $900 and then 10% for any charges between $901 and $3600. This is also used for professional services that are incurred during a hospital stay. In-patient care from a non-participating hospital requires a 100% payment for services, minus $650 per day. Non-participating professional services at a hospital are charged at 50% of the negotiated fee and 100% of any extra charges.

Outpatient Coverage - There is also a Preservice review required for certain outpatient procedures under this plan. For this type of care received at a participating facility, the charges are 30% of the negotiated fee up to $900, and then 10% from $901 to $3600, once the deductible has been met. If outpatient care is performed at a non-participating facility, your employees will have to pay 100% of their care, minus a $380 per day benefit.

Prescription Drugs - Generic prescriptions from a participating pharmacy will require a $15 co-pay. If a brand name prescription is purchased and there are no generic alternatives available, the co-pay goes up to $25. In the event that an employee prefers a brand name prescription and there is a generic alternative available, they will need to pay a $15 co-pay, plus the difference in price between the generic and brand name prescription. There is a 50% payment of the limited fee schedule required for prescriptions that are purchased from a non-participating pharmacy.

Physical Exam - This plan provides for preventative physicals, and there is a $25 co-pay for an office visit with a participating provider. There is a $200 limit for this care for members who have been with Anthem Blue Cross for at least 8 months, and a $100 limit for this care if they have been with Anthem Blue Cross for less time. For covered services received in addition to the office visit, your employees’ would need to pay 30% of the charges up to $900, and 10% of the charges from $901 to $3600. If your employees’ receive a physical exam from a non-participating physician, the cost goes up to 50% of the negotiated fee and 100% of any additional fees.

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