Anthem Blue Cross Copay

Posted : admin On 1/3/2022

No copay (deductible waived) 40% (benefit limited to $150/calendar year) Routine physical exams, immunization, diagnostic X-ray & lab for routine physical exam (members 19 years and older) No copay/exam (deductible waived) 40% (benefit limited to $150/calendar year) CONTINUED ON NEXT PAGE Your Summary of Benefits Anthem Blue Cross PPO. Anthem Blue Cross Life and Health Insurance Company County of San Luis Obispo Your Plan: Anthem Select PPO Your Network: Select PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. $20 copay per visit 40% coinsurance Specialist care visit Deductible does not apply to In-Network providers. $25 copay per visit Specialist care visit $35 copay per visit Family Planning Services Infertility studies & tests. Infertility treatment. Tubal Ligation Vasectomy Counseling & consultation Abortion Pregnancy & Maternity Care 50% coinsurance 50% coinsurance No Copay.

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Benefit Details

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  • Covered Drug List

Medical Deductible

Individual:
N/A
Family:
N/A
Per Person:
N/A

Drug Deductible

Individual:
N/A
Family:
N/A
Per Person:
N/A
Cross

Medical & Drug Deductible

Individual:
$6,850
Family:
$13700
Per Person:
$6850

Medical Max Out-of-Pocket

Individual:
N/A
Family:
N/A
Per Person:
N/A

Anthem Blue Cross Dental Copay

Drug Max Out-of-Pocket

Individual:
N/A
Family:
N/A
Per Person:
N/A

Medical & Drug Max Out-of-Pocket

Individual:
$6,850
Family:
$13700
Per Person:
$6850

Anthem Blue Cross Therapy Copay

Eligible Locations

County

Anthem Blue Cross CopayCross

ALL

Valid in these Zip Codes

N/A

Primary Care Physician

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Specialist

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A
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Prescription Drugs

Preferred Brand Drugs

Copay:
Not Applicable
Coinsurance:
0.00% Coinsurance after deductible
Exclusions:
N/A
Benefit Explanation:
30 day supply

Generic Drugs

Copay:
Not Applicable
Coinsurance:
0.00% Coinsurance after deductible
Exclusions:
N/A
Benefit Explanation:
30 day supply

Specialty Brand Drugs

Copay:
Not Applicable
Coinsurance:
0.00% Coinsurance after deductible
Exclusions:
N/A
Benefit Explanation:
30 day supply

Non-Preferred Brand Drugs

Copay:
Not Applicable
Coinsurance:
0.00% Coinsurance after deductible
Exclusions:
N/A
Benefit Explanation:
30 day supply
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Hospital Services

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Inpatient Services

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Emergency Room

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Urgent Care

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A
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Maternity

Labor and Delivery Hospital Stay

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Pre and Postnatal Office Visit

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A
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Routine Eye Exams for Children

Anthem blue cross hmo copay
1 Visit(s) per year
Copay:
No Charge
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A
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Dental

Routine Dental Checkups for Children

Anthem Blue Cross Copay
2 Visit(s) per Year

Anthem Tier 3 Copay

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Routine Dental Checkups for Adults

Copay:
N/A
Coinsurance:
N/A
Exclusions:
N/A
Benefit Explanation:
N/A

Basic Dental Care - Child

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Basic Dental Care - Adult

Copay:
N/A
Coinsurance:
N/A
Exclusions:
N/A
Benefit Explanation:
N/A

Major Dental Care - Child

Copay:
No Charge after deductible
Coinsurance:
Not Applicable
Exclusions:
N/A
Benefit Explanation:
N/A

Major Dental Care - Adult

Copay:
N/A
Coinsurance:
N/A
Exclusions:
N/A
Benefit Explanation:
N/A
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Spouse, Yes; Adopted Child, No; Foster Child, No; Ward, No; Stepson or Stepdaughter, No; Self, Yes; Child, No; Court Appointed Guardian, No; Life Partner, Yes

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