MEDICAL BENEFITS – Silver Plan
Base Plan Anthem Blue Cross and Blue Shield Silver PPO 3500/30%/9100
Network
Out-of-Network
Calendar Year Deductible
$3,500 single $7,000 family $9,100 single $18,200 family
$8,750 single $17,500 family $22,750 single $45,500 family
Annual Out-of-Pocket Maximum
Physician Services Office Visits
$40
50% after deductible
Specialist Visits
$90 $90
50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Urgent Care
Adult Preventive Services
Covered 100% - no copay Covered 100% - no copay
Well Child Care Exam
Outpatient Services Outpatient Surgery
30%
Diagnostic Lab / X-Ray MRI, CT Scan and PET Hospital Services Inpatient Hospitalization
30% after deductible 30% after deductible
30% after deductible
50% after deductible
Emergency Room (Copay waived if admitted)
$1,000 + 30% (deductible waived)
$1,000 + 30% (deductible waived)
Prescription Drugs Rx Deductible
No Rx deductible applies
-
Retail Pharmacy Generic Brand Formulary
$10 $40 $80
50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
Brand Non-Formulary
Specialty
25%; max charge $500
Number of Day Supply
To 30-day supply
-
Mental or Nervous Disorders & Substance Abuse Inpatient
30% after deductible
50% after deductible 50% after deductible
Outpatient
$40
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