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Summary of Benefits Protect 45

Non-Grandfathered Plans Effective January 1, 2012

 
Provisions In-Network Out-of-Network
Annual Deductible

 

$0

 

 

$1,000 per member, no family limit

 
Out-of-Pocket Maximum (annual)

 

$8,000 per member
$16,000 family aggregate

 

 

$15,000 + deductible per member
Lifetime Maximum Benefit

 

No lifetime maximum
$2,000,000 calendar year maximum

 

Hospital Admission Copay

(Including Mental Health and Substance Abuse hospital admissions)

 

First hospital admission only per person,
per year $3,000

 

First hospital admission only
per person, per year $5,000 +
deductible if not already met

 

Inpatient & Outpatient Hospital Services

 

 

50% of negotiated fee

 

 

Plan pays 50% of allowable fee,
up to $540 per day

 


Emergency Room Deductible

 

 

$100

 

 

Office Visits

 

 

$45 copay per visit

 

 

Plan pays 50% of allowable fee

 

 

Physical Therapy, Speech Therapy
(including chiropractic care)
There is a maximum of 25 visits per year Maximum limit includes visits to both in-network and out-of-network providers

 

 

$45 copay, plus 50% of the
remaining negotiated fee

 

 

Plan pays 50% of the allowable fee,
up to $40 per visit

 

 

Preventive (ages 7 and up)
1 Physical per year

 

 

100% plan paid, not subject to the deductible

 

Plan pays up to $250

 

Well Woman Care

1 Visit per year

 

100% plan paid, not subject to the deductible

 Plan pays 50% of allowable fee

 

Well-Baby Care (ages 0–6)

 

 

100% plan paid, not subject to the deductible

 

 

Plan pays 50% of allowable fee

 
Prescription Drugs

Prescription Drugs Annual Deductible


Applies to brand-name drugs only

$150 per person
$300 family aggregate
(combines in/out-of-network charges)

Some Specialty Drugs are only available
through Anthem Blue Cross CuraScript mail order program

 

 

Prescription Drug - Retail (30-day supply)

Generic

Brand-Formulary
Brand - Non-Formulary

 

 

$10
$25
$45

 

Retail in-network copay, plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount

 

Prescription Drug—Mail Order ( 60 Day Supply)
(Anthem Blue Cross Express Scripts Only)

 

Generic

Brand-Formulary
Brand - Non-Formulary

 

 

 

 

$10
$25
$45

 

Retail in-network copay, plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount

 

Self-injectable drugs - Retail or mail order
(excluding insulin)

 

30% of prescription drug maximum allowed amount

 

 

Not covered

 

 

Mental Health and Substance Abuse

 
Provisions In-Network Out-of-Network Benefits (6)

 

Inpatient

 

 

50% of negotiated fee

 

Plan pays 50% of allowable fee up to $540 per day

 

Outpatient

 

 

50% of negotiated fee

 

 

Plan pays 50% of allowable fee up to $540 per day

 

First hospital admission per year

 

 

$3,000 copay

 

 

$5,000 copay

 

 

Offfice Visits/Therapy Sessions

 

 

$45 copay

 

 

Plan pays 50% of allowable fee up to $540 per day

Note: Where a maximum number of visits per year/per day is indicated, it includes both in-network and out-of-network services.
1. Payments to out-of-network providers are based on negotiated fees. You pay any excess charges.
2. Waived if admitted
3. Copays do not apply toward satisfaction of the annual deductible or out-of-pocket maximum
4. Rx deductible is not integrated with the medical deductible
5. Customary & Reasonable
6. Member is responsible for all charges in excess of plan payments.

This chart is not a contract. Please refer to each plan’s Medical Plan Document and Disclosure Form or Certificate.
Benefits listed are per-member costs, subject to deductibles and copayments unless otherwise stated.