Anthem Blue Cross Small Group PPO $10 Co-Pay Plan:
The last PPO type plan offered to small group customers is the PPO $10 Co-pay plan. This plan offers greater savings for employees who need a smaller co-pay for their medical services, as well as a smaller amount of annual out-of-pocket expenses. The lifetime maximum benefit for this plan is $5,000,000.
Annual Deductible - This plan has a $250 deductible for all services, minus office visits, prescriptions, an annual physical exam, and Healthy Check screenings.
Annual Out-of-Pocket Maximum - This plan requires a maximum out-of-pocket expense of $2500 for participating providers and a $5000 maximum for non-participating providers. These amounts are accumulated individually, which means that the absolute maximum is $7500, if both non-participating and participating service providers are used.
Office Visits - This plan has a $10 co-pay for office visits. There is a maximum amount of 12 visits per year. After this point, your employees’ would need to pay 30% of the negotiated fee for their office visits. If they select an out-of-network provider for their office visits, a 30% co-insurance payment is required, as well as payment of 100% of any excess fees. Professional office services, such as maternity care, lab work or x-rays are charged in the following manner: 10% of the negotiated fee once the deductible has been met for participating providers and 30% of the customary and reasonable fee for non-participating providers. There is also a requirement of 100% payment for any non-covered charges received by a non-participating provider.
Hospital Inpatient Care - This plan offers one of the lowest requirements for hospital care. A 10% co-insurance fee is required for participating hospitals, once the deductible has been met. A pre-service review is required before this coverage will take effect. If a non-participating hospital is used, the fee moves up to 30% of the customary and reasonable charges as well as 100% payment for excess fees. If your employees need professional services while they are an inpatient, the fees are calculated in the same manner.
Outpatient Care - If your employees’ need specific outpatient services, such as diagnostic procedures, there is a pre-service review before the benefits will take effect. Once this has been completed, the charges for outpatient care with a participating provider or clinic are 10% of the negotiated fee, after the deductible. Non-participating outpatient care facilities or doctors will necessitate a payment of 30% of the customary and reasonable fee, and 100% for any extra fees that are not covered by this plan.
Prescription Drugs - These medications are not subject to the annual deductible. As long as your employees’ visit a participating pharmacy, the co-pay for generic medications is only $10. For brand name prescriptions, this price moves up to $20. If a non-participating pharmacy is used, this fee goes up to 30% of the limited fee schedule plus 100% of any uncovered charges.
Physical Exam - Anthem Blue Cross provides a $200 maximum amount for a physical exam, as long as your employee has been covered for more than six months. If they have not been covered this long, the covered amount drops down to $100. There is a $10 co-pay and 10% co-insurance requirement for physicals at a participating physician’s office, and a 30% co-insurance payment for non-participating physicians.
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