Indiana Blue Access PPO Plan 2 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	$250 individual / $500 family	$500 individual / $1,000 family
	$500 individual / $1,000 family	$1,000 individual / $2,000 family
	$1,000 individual / $2,000 family	$2,000 individual / $4,000 family
	$2,500 individual / $5,000 family	$5,000 individual / $10,000 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)	$2,250 individual / $4,500 family	$4,500 individual / $9,000 family
	$2,500 individual / $5,000 family	$5,000 individual / $10,000 family
	$3,000 individual / $6,000 family	$6,000 individual / $12,000 family
	$4,500 individual / $9,000 family	$9,000 individual / $18,000 family
Physician Office Visits	$25 co-pay for office visit², 20% for other services¹	50%¹
Preventive Care	$25 co-pay for office visit², 20% for other services¹	50%¹
Well Child Care	$25 co-pay for office visit², 20% for other services¹	50%¹
Prescription Drugs - Retail Retail: 30-day supply

	• Tier 1 Drugs³	$15 per prescription²	50% - minimum $60 payment
	• Tier 2 Drugs³	$30 per prescription²	50% - minimum $60 payment
	• Tier 3 Drugs³	$60 per prescription²	50% - minimum $60 payment
	• Tier 4 Drugs³	25% per prescription ($2,500 combined out-of-pocket maximum for retail and mail service)	50% - minimum $60 payment
Prescription Drugs - Mail Service Mail Service: 90-day supply
	• Tier 1 Drugs³	$30 per prescription²	Not covered
	• Tier 2 Drugs³	$75 per prescription²	Not covered
	• Tier 3 Drugs³	$150 per prescription²	Not covered
	• Tier 4 Drugs³	25% per prescription ($2,500 combined out-of-pocket maximum for retail and mail service)	Not covered
Diagnostic Services		20%¹	50%¹
Inpatient Hospital Services		20%¹	50%¹
Outpatient Services		20%¹	50%¹
Emergency Room		20%¹	20%¹
Urgent Care		20%¹	20%¹
Ambulance (includes air)		20%¹	20%¹
Maternity Services		Not covered
Optional Maternity Rider Subject to a 12-month waiting period		20%¹	50%¹
Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined: Physical Therapy and Manipulation Therapy - 20 visits maximum Speech Therapy - 20 visits maximum Occupational Therapy - 20 visits maximum		$25 co-pay for office visit², 20% for other services¹	50%¹
Mental Health and Substance Abuse
	• Inpatient	20%¹	50%¹
	• Outpatient	20%¹	50%¹
	• Physician office services	$25 co-pay for office visit², 20% for other services¹	50%¹
Home Health Care Maximum visits per benefit period - 60 visits		20%¹	50%¹
Hospice		20%¹	20%¹
Durable Medical Equipment $4,000 maximum per benefit period		20%¹	50%¹
Prosthetic Devices $4,000 maximum per benefit period		20%¹	50%¹

Human Organ and Tissue Transplant Services Kidney and cornea transplant services covered same as any other illness under medical		20%¹	50%^1,2 (non-network transplant facility)
	• Transportation, Lodging and Meals	20%¹	50%^1,2
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.

Tier 1 Drugs -	Nearly all Tier 1 drugs are Preferred Generic Prescription Drugs, but Tier 1 may also include some lower cost brand-name drugs with the greatest therapeutic value.
Tier 2 Drugs -	Preferred Brand-Name and/or Generic Drugs that are lower-cost and provide greater therapeutic value than comparable brand-name drugs.
Tier 3 Drugs -	Nearly all Tier 3 drugs are Brand-Name drugs that cost more or are less efficient than comparable drugs on lower tiers, but Tier 3 may also include some high-cost generic drugs.
Tier 4 Drugs -	Generally includes self-injectable drugs. The list of Tier 4 Drugs can be found at anthem.com or by calling the number on the back of your ID card.

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 Plan 2 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 Plan 2 Benefits Overview, the terms of the contract or certificate of coverage will prevail.