Indiana Blue Access Value 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 | $2,000 individual / $4,000 family | $4,000 individual / $8,000 family | |
| $3,000 individual / $6,000 family | $6,000 individual / $12,000 family | ||
| $5,000 individual / $10,000 family | $10,000 individual / $20,000 family | ||
| $10,000 individual / $20,000 family | $20,000 individual / $40,000 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) | $5,000 individual / $10,000 family | $10,000 individual / $20,000 family | |
| $6,000 individual / $12,000 family | $12,000 individual / $24,000 family | ||
| $8,000 individual / $16,000 family | $16,000 individual / $32,000 family | ||
| $13,000 individual / $26,000 family | $26,000 individual / $52,000 family | ||
| Physician Office Visits | $30 co-payment2,3 for the first 2 office visits per person per calendar year. 3+ office visits - not covered | 40%3 for visits 1 and 2. 3+ office visits - not covered | |
|
Preventive Care Lab/X-Ray for routine Pap smear, annual mammogram, colorectal cancer screening or PSA screening ONLY. Other preventive care services are not covered. |
30%1 | 40%1 | |
| Well Child Care | Not covered | ||
|
Prescription Drugs - Retail Retail: 30-day supply |
|||
| • Generic Formulary | $10 per prescription2 | Not covered | |
| • Brand Name Formulary | $200 deductible per calendar year, then $25 per prescription2 | Not covered | |
| • Generic Non-formulary | $10 per prescription2 | Not covered | |
| • Brand-name Non-formulary | Not covered | ||
|
Prescription Drugs - Mail Service Mail Service: 90-day supply |
|||
| • Generic Formulary | $20 per prescription2 | Not covered | |
| • Brand Name Formulary | $200 deductible per calendar year, then $50 per prescription2 | Not covered | |
| • Generic Non-formulary | Not covered | ||
| • Brand-name Non-formulary | Not covered | ||
| Diagnostic Services $300 maximum per member per calendar year for combined network and non-network (Includes lab work, X-rays and Outpatient Diagnostic Services. Preventive services excluded from the $300 limit) |
30%1 (not subject to deductible) | 40%1 (not subject to deductible) | |
| Inpatient Hospital Services | 30%1 | 40%1 | |
| Outpatient Services | 30%1 | 40%1 | |
| Emergency Room | 30%1 (additional $60 copayment if not admitted2) | 30%1 (additional $60 copayment if not admitted2) | |
| 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 | Not covered | Not covered | |
| Mental Health and Substance Abuse | |||
| • Inpatient | 30%1 | 40%1 | |
| • Outpatient | $30 co-payment2,3 for the first 2 office visits per person per calendar year. 3+ office visits - not covered | 40%3 for visits 1 and 2. 3+ office visits - not covered | |
|
Home Health Care Maximum visits per benefit period - 60 visits |
30%1 | 40%1 | |
| Hospice | 30%1 | 30%1 | |
| Durable Medical Equipment | Not covered | ||
|
Prosthetic Devices $4,000 maximum per benefit period |
30%1 | 40%1 | |
| Human Organ and Tissue Transplant Services | 30%1 | 40%1 (coinsurance does not apply to out-of-pocket maximum) |
| 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.
Physician office visits and mental health office visits are combined for a maximum of 2 visits per person, per calendar year. Subsequent office visits are not covered.
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 Value 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 Value Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail.
