InnFocus Anthem Blue Cross Plans
The charts below outline each plan’s provisions, deductibles, copays and coinsurance of the plan:
- Anthem Blue Cross HDHP PPO with HSA (Nationwide)
- Anthem Blue Cross PPO (Nationwide)
Nationwide Plans
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| Anthem Blue Cross | HDHP PPO with HSA (Nationwide) | PPO (Nationwide) | ||
|---|---|---|---|---|
| Key Features | In-Network | Out-of-Network2 | In-Network | Out-of-Network2 |
| Annual Calendar Year Deductible | ||||
| Individual | $3,400 | $8,400 | $500 | $1,500 |
| Family | $6,800 | $16,800 | $1,500 | $4,500 |
| Out-of-Pocket Maximum | ||||
| Individual (includes deductible) | $5,000 | $15,000 | $3,500 | $10,500 |
| Family (includes deductible) | $10,000 | $30,000 | $7,000 | $21,000 |
| Physician Services (after deductible unless specified) | ||||
| Office Visit | No charge | 30% | $20 primary care $40 specialist | 30% after deductible |
| Preventive Care | No charge (deductible waived) | 30% | No charge (deductible waived) | 30% after deductible |
| Diagnostic Lab and X-Ray | No charge | 30% | 10% after deductible | 30% after deductible |
| Complex Lab and X-Ray | No charge | 30% | 10% after deductible | 30% after deductible |
| Hospital Services | ||||
| Inpatient (per admission) | No charge | 30% | 10% after deductible | 30% after deductible |
| Outpatient Surgery | No charge | 30% | 10% after deductible | 30% after deductible |
| Emergency Treatment | ||||
| Emergency Room (waived if admitted) | No charge | $150 copay then 10% | ||
| Retail Prescriptions¹ (30-day supply) | ||||
| Pharmacy Deductible | Combined with medical deductible | N/A | ||
| Tier 1 Lower Cost Generic/Generic | $5 / $15 | 30% up to $250 | $5 / $20 | 50% to $250 max |
| Tier 2 | $40 | $40 | ||
| Tier 3 | $60 | $60 | ||
| Tier 4 | 30% up to $250 | 30% to $250 max | ||
| Mail-Order Prescriptions¹ (90-day supply) | ||||
| Tier 1 Lower Cost Generic/Generic | $12.50 / $37.50 | Not covered | $12.50 / $50 | Not covered |
| Tier 2 | $120 | $120 | ||
| Tier 3 | $180 | $180 | ||
| Tier 4 | 30% up to $250 | 30% to $250 max | ||
1 For prescription drug formulary information, visit carrier website or contact Members Services via the toll-free number on your ID card.
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