Your Responsibility
You are ultimately responsible for understanding how the plan works and your financial responsibility for all services. The Plan will not provide any reimbursement for non-covered services. You may be responsible for the total amount billed by your provider/laboratory for non-covered services, regardless of whether such services are performed by a network provider/laboratory or out-of-network provider/laboratory. You’re ultimately responsible for ensuring that the admission, services, and expenses have been pre-certified (if required) and network providers are using network laboratories/sites for your testing and treatment. You may also want to know the provider’s charges to calculate your out-of-pocket responsibility. Although member services can assist you with this information, the final maximum allowed amount for your claim will be based on the actual claim and coding submitted by the provider.
Plans
Deductible
Blue, Green and Orange Plans: This is the amount you must pay each year for your covered health care and prescription drugs before the plan begins to share eligible health care costs with you. The exception is for preventive care and preventive prescriptions, which are covered before you meet your deductible.
There are separate in- and out-of-network deductibles for all three plans and they do not cross apply. If you are using providers outside of the Anthem Blue Cross and Blue Shield network, you’ll pay more for coverage, and be subject to a separate, higher deductible.
Purple Plan: The deductible only applies to certain health care services before the plan begins to share eligible health care costs with you. The deductible does not apply to preventive care, primary care and specialist visits, emergency room and urgent care visits, or prescriptions.
Under all plans: Family coverage includes coverage for Employee & Spouse/Domestic Partner, Employee & Child(ren), and Employee & Family. If you elect family coverage under the Purple, Blue or Green Plans, benefits that are subject to the deductible begin once the entire family deductible is met. If you elect family coverage under the Orange Plan, benefits begin for a family member once that family member satisfies the individual deductible, and benefits begin for the entire family once the entire family deductible is met.
| Purple | Blue | Green | Orange |
|---|---|---|---|
In-network deductible (individual/family)
Out-of-network deductible - N/A | In-network deductible (individual/family)
Out-of-network deductible (individual/family) | In-network deductible (individual/family)
Out-of-network deductible (individual/family) | In-network deductible (individual/family)
Out-of-network deductible (individual/family) |
Preventive care, prescription drugs, and benefits that are subject to a copay are not subject to the deductible. For all other services:
The individual deductible must be met before benefits begin for the individual.
The entire family deductible must be met before benefits begin for any covered family member. Any combination of you and/or one or more of your dependents can incur expenses to meet the family deductible. | Preventive care, and preventive prescriptions are not subject to the deductible. For all other services:
The individual deductible must be met before benefits begin for the individual.
The entire family deductible must be met before benefits begin for any covered family member. Any combination of you and/or one or more of your dependents can incur expenses to meet the family deductible. | Preventive care, and preventive prescriptions are not subject to the deductible. For all other services: The individual deductible must be met before benefits begin for the individual. The entire family deductible must be met before benefits begin for any covered family member. Any combination of you and/or one or more of your dependents can incur expenses to meet the family deductible. | Preventive care, and preventive prescriptions are not subject to the deductible. For all other services: The individual deductible must be met before benefits begin for the individual. Benefits begin for a family member once that family member satisfies the individual deductible. Benefits begin for the entire family once the entire family deductible is met. Any combination of you and/or one or more of your dependents can incur expenses to meet the family deductible. |
Coverage Level
You can choose coverage for Employee-only, Employee & Spouse/Domestic Partner, Employee & Children, or Employee & Family.
Per-Paycheck Contribution
This is the amount that is deducted from each of your paychecks for your health plan coverage. Under the Purple and Blue Plans, you pay a higher per paycheck contribution and a lower deductible as compared to the Green and Orange Plans. Under the Orange Plan, your per paycheck contribution is the lowest but with the highest deductible, as compared to the Purple, Blue and Green Plans.
Copayment
Certain services are under the Purple plan are subject to a copayment. This is a predetermined rate you pay for health care services at the time of care. Services that are subject to a copayment are not subject to the deductible, and do not apply towards the deductible.
| Purple (In-Network Only) | |
|---|---|
| Primary Care Physician (PCP) | $25 Copayment |
| Mental Health (outpatient/professional office visit) | $25 Copayment |
| Livehealth Online (including mental health visits) | $25 Copayment |
| Specialist | $45 Copayment |
| Urgent Care | $45 Copayment |
| Emergency Room | $300 Copayment |
Coinsurance
This is the percentage of the cost that you pay for covered health care and prescription drugs after you've met the deductible. Under the Purple plan, coinsurance would only apply to services that are subject to the deductible.
| Under the PURPLE Plan option, you pay: In-network - 20% Out-of-network - N/A | Under the BLUE Plan option, you pay: In-network - 20% Out-of-network - 40% | Under the GREEN Plan option, you pay: In-network - 20% Out-of-network - 40% | Under the ORANGE Plan option, you pay: In-network - 10% Out-of-network - 30% |
Providers in the Anthem Blue Cross and Blue Shield network have agreed to specific prices for covered services. It costs less to use providers in the network. You will pay higher coinsurance when you use out-of-network* providers. If you choose to visit an out-of-network provider under the Blue, Green and Orange Plans, the visit will be subject to the separate out-of-network deductible and coinsurance. In addition, out-of-network doctors may charge more than Reasonable and Customary (R&C) charges, and you will be responsible for any charges that are above the R&C amount.
If you’re enrolled in a health plan, you can see if your provider participates in the network by visiting Anthem.com. If you’re not enrolled in a health plan, you can use this tool to find a provider in the network.
*Under the Purple Plan, there are no benefits for out-of-network care except for urgent and emergency care.
Out-of-Pocket Maximum
This is the most you will pay out of your pocket in a given calendar year for your covered health care and prescription drugs. When you reach the out-of-pocket maximum, the plan begins paying 100% for eligible covered services for the remainder of that calendar year. Under the Blue, Green and Orange plans, there are separate deductible and out-of-pocket maximums for your in-network and out-of-network utilization. They do not cross-apply.
For example, if you spend $200 on in-network services under the Green Plan, Employee-only plan, this $200 applies to your $1,700 in-network deductible and $4,200 in-network out-of-pocket maximum, and won’t apply to your out-of-network deductible or out-of-pocket maximum.
For example, if you spend $200 on in-network services under the Green Plan, Employee-only plan, this $200 applies to your $1,700 in-network deductible and $4,200 in-network out-of-pocket maximum, and won’t apply to your out-of-network deductible or out-of-pocket maximum.
| Purple | Blue | Green | Orange |
| The Blue Plan out-of-pocket maximums are (individual/family): In-network - $4,000/$8,000 Out-of-network - N/A | The Blue Plan out-of-pocket maximums are (individual/family): In-network - $3,450/$6,900 Out-of-network - $6,450/$12,900 | The Green Plan out-of-pocket maximums are (individual/family): In-network - $4,200/$8,400 Out-of-network - $7,200/$14,400 | The Orange Plan out-of-pocket maximums are (individual/family): In-network - $5,200/$10,400 Out-of-network - $8,200/$16,400 |
| Once the individual out-of-pocket maximum is reached by one family member, claims for that individual will be paid at 100%. Once the family’s combined expenses reach the family out-of-pocket maximum, claims will be paid at 100% for all covered family members’ eligible expenses for the remainder of the calendar year. | If you elect Family coverage under the Blue health plan, there is no individual out-of-pocket maximum. Claims will be paid at 100% by the Plan only when the family out-of-pocket maximum is met. Any combination of you and/or one or more of your dependents can incur expenses to meet the family out-of-pocket maximum. | Once the individual out-of-pocket maximum is reached by one family member, claims for that individual will be paid at 100%. Once the family’s combined expenses reach the family out-of-pocket maximum, claims will be paid at 100% for all covered family members’ eligible expenses for the remainder of the calendar year. | Once the individual out-of-pocket maximum is reached by one family member, claims for that individual will be paid at 100%. Once the family’s combined expenses reach the family out-of-pocket maximum, claims will be paid at 100% for all covered family members’ eligible expenses for the remainder of the calendar year. |
Certain medical services require precertification for you to receive benefits. To precertify, contact Anthem Blue Cross and Blue Shield at 1-855-285-4212. Note: If precertification is not required, it does not mean that a service will necessarily be covered. Please see the Summary Plan Description for a list of covered services and exclusions, and the Medical page to see the list of Services Requiring Precertification.
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