Summary of Benefits HMO Advantage 100 Non-Grandfathered Plans Effective January 1, 2012
|
|
| In-Network | HMO 100% |
Annual Deductible
|
None |
Out-of-Pocket Maximum |
$1,750 Individual
|
Professional Services
|
|
Office Visits
|
$10 per visit |
Specialist & Consultants
|
$10 per visit |
Hospital
|
|
Emergency Care
|
$100 per visit |
Inpatient Hospital Services and Surgical Facilities
|
No charge |
Other Professional Services
|
No charge |
Outpatient Medical Services
|
No charge |
Health Maintenance
|
|
Outpatient Annual Physical Examination,
|
No Charge* |
Mental and Nervous and Substance Abuse
|
|
Inpatient
|
No charge* |
Outpatient
|
No charge* |
Other Services
|
|
Home Health Care
|
No charge |
Physical Therapy, Occupational Therapy, Chiropractic Care
|
No charge |
Prescription Drugs
|
|
Prescription Drug Deductible
|
$150 Brand Deductible per member |
Participating Pharmacies (30-day supply) |
$10 Generic $45 Brand-Non-Formulary
|
Mail Order (60-day supply)
|
$10 Generic $45 Brand-Non-Formulary
|
Self-Administered Injectable Drugs (excluding insulin)
|
30% of prescription drug maximum allowed amount |
Note: This summary is a brief review of benefits. It is not a contract and does not replace the master policy. It is as accurate as possible, but we cannot be responsible for any errors and make no warranty of any kind. *These limitations, co-pays and benefit maximums do not apply to severe mental disorders as defined in California state law (other than primary substance abuse or developmental disorder). Severe mental disorders are subject to the same co-pays and benefit maximums applicable to other medical conditions for covered services. In order or receive coverage, services must be rendered by a Anthem Blue Cross behavioral health provider. |
