Anthem Blue Cross Small Group PPO $40 Co-Pay Plan:

The third small group plan available to your employees’ from Anthem Blue Cross is the PPO $40 co-pay plan. This plan allows a little more freedom in the amount of office visits that are offered each year, and features a lower deductible. Let’s take a look at what this plan has to offer.

Annual Deductible - There is a $500 annual deductible for medical services under this plan. Office visits, Healthy Check screenings and prescription drugs are not subject to this deductible.

Lifetime Maximum - There is a $5,000,000 maximum benefit for this health plan. This includes services provided by both in and out-of-network providers.

Annual Out-of-Pocket Maximum - Each year, your employees’ will need to provide $4500 out-of-pocket for medical services received from an in-network provider. There is a $10,000 maximum for services received from an out-of-network provider. However, once this has been reached, your employees will not have to pay any additional money for covered services, unless the charge is over the allotted amount.

Office Visits - As mentioned earlier, these visits are not subject to the annual deductible. There is a $40 co-pay for the first 12 office visits each year for in-network providers. After this point, your employees will need to pay 45% of the negotiated fee. For out-of-network office visits, they will need to pay for 50% of the negotiated fee and 100% of any additional charges.

Other Services - These professional services are normally defined as lab work, x-rays and other fees. For in-network providers, they will need to pay 40% of the negotiated fee once they have reached their deductible. Out-of-network providers require a payment of 50% of the negotiated fee and 100% of any excess fees.

Hospital Inpatient Coverage - Once the deductible has been met, in-network hospital care requires a payment of 40% of the negotiated fee. Out-of-network hospitals require 100% payment, minus $650 per day, after the deductible has been met. In-network professional charges as an inpatient are 40% of the negotiated fee, after the deductible. For professional services received from an out-of-network hospital as an inpatient, your employees will be required to pay 50% of the negotiated fee and 100% of the additional fees that are not covered under this plan.

Outpatient coverage - Once again, for in-network providers, your employees will be responsible for 40% of the negotiated fee. For out-of-network providers, this moves up to 100% minus $380 per day. These charges are required once the deductible has been met.

Prescription Drugs - This plan has a slightly different method for calculating prescription co-pays. As mentioned above, these medications are not subject to the annual deductible. Medication purchased from a participating pharmacy will be charged as follows: Generic prescriptions will require a $15 co-pay. Brand name prescriptions, in the absence of a generic alternative will have a $25 co-pay, once the annual $150 brand name deductible has been reached. If a generic alternative is available, this changes to a $10 co-pay, plus the difference in cost between the brand name prescription and the generic alternative, once the $150 brand name deductible has been met. For prescriptions purchased from a non-participating pharmacy, this changes to 50% of the limited fee schedule plus 100% of any excess fees, after the deductible has been met.

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