Indiana Blue Access Economy Plan Benefit Summary
| BENEFIT CATEGORY | ANTHEM PAYS |
| Lifetime Maximum Benefit | $7 million maximum per member |
| BENEFIT CATEGORY | NETWORK YOU PAY | NON-NETWORK YOU PAY |
| Calendar-year Deductible | $500 individual / $1,000 family | $1,500 individual / $3,000 family | |
| $1,000 individual / $2,000 family | $2,000 individual / $4,000 family | ||
| $1,500 individual / $3,000 family | $2,500 individual / $5,000 family | ||
| $2,500 individual / $5,000 family | $3,500 individual / $7,000 family | ||
| • Deductible Carryover | Covered medical expenses incurred during the last 3 months of the calendar year, which are applied against the deductible but do not satisfy the calendar year deductible, may be carried over and applied against the deductible for the next calendar year. If the deductible is met, there is no carry-over. |
| Out-of-Pocket Maximum (including deductible) | $3,500 individual / $7,000 family | $7,500 individual / $15,000 family | |
| $4,000 individual / $8,000 family | $8,000 individual / $16,000 family | ||
| $4,500 individual / $9,000 family | $8,500 individual / $17,000 family | ||
| $5,500 individual / $11,000 family | $9,500 individual / $19,000 family | ||
| Physician Office Visits | $30 co-payment2,3 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30%1 coinsurance | 50%1 | |
| Preventive Care | Not covered | ||
| Well Child Care | Not covered | ||
|
Prescription Drugs - Retail Retail: 30-day supply |
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| • Generic | $15 per prescription2, $500 maximum per person per calendar year | Not covered | |
| • Brand Name | Not covered | ||
| Prescription Drugs - Mail Service | Not covered | ||
| Diagnostic Services | 30%1 | 50%1 | |
| Inpatient Hospital Services | 30%1 | 50%1 | |
| Outpatient Services | 30%1 | 50%1 | |
| Emergency Room | 30%1 | 30%1,4 | |
| Urgent Care | 30%1 | 30%1 | |
| Ambulance (includes air) | 30%1 | 30%1 | |
| Maternity Services | Not covered | ||
| Optional Maternity Rider | Not available | ||
|
Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined: Physical Therapy and Manipulation Therapy - 10 visits maximum
Speech Therapy - 10 visits maximum Occupational Therapy - 10 visits maximum |
$30 co-payment2,3 for the first 3 office visits per person per calendar year. 4+ office visits - subject to deductible and 30%1 coinsurance | 50%1 | |
| Mental Health and Substance Abuse | Not covered | ||
|
Home Health Care Maximum visits per benefit period - 60 visits |
30%1 | 50%1 | |
| Hospice | 30%1 | 30%1 | |
|
Durable Medical Equipment $4,000 maximum per benefit period |
30%1 | 50%1 | |
|
Prosthetic Devices $4,000 maximum per benefit period |
30%1 | 50%1 | |
|
Human Organ and Tissue Transplant Services Kidney and cornea transplant services covered same as any other illness under medical |
30%1 | 50%1 (non-network transplant facility), copayment does not apply to out-of-pocket maximums |
|
| • Transportation, Lodging and Meals | 30%1 | 50%1 | |
| Anthem Blue Preferred Term Life Option | Available as option - additional cost | ||
| Anthem Dental Blue Option | Available as option - additional cost | ||
Services subject to calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other.
Co-payment does not apply to deductible or out-of-pocket maximums.
$30 copayment for the first 3 office visits includes Physician office visits and Outpatient Therapy office visits combined. Subsequent office visits subject to the deductible and 30% coinsurance.
Emergency Care rendered by a Non-network Provider will be covered as a Network service, however, the member may be responsible for the difference between the Non-network Provider's charge and the amount that Anthem determines is the maximum amount payable for covered services the member receives, in addition to any applicable copayment or deductible.
Blue Access PPO Network
These plans are available with the Blue Access PPO network. to find a doctor or local hospital, visit www.anthem.com and select the "Find a Doctor" button for a complete list of providers within the network.
Brief Outline of Coverage
This Anthem Blue Access Economy Plan Benefits Overview is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the contract or certificate of coverage. In the event of a conflict between the contract or certificate of coverage and this Anthem Blue Access Economy Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail.
