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Premier 1500 1 MemberAnthem Logo

The Premier 1500 1 Member plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: PPO
Deductible: $1,500
In-Patient Hospital Co-Payment/Coinsurance: 25%
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: Yes
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Premier 1500 1 Member Summary:

In Network Out of Network
Annual Deductible Individual: $1,500 Family: $3,000 Individual: $1,500 Family: $3,000
Annual Out-Of-Pocket Limit Individual: $4,500 Family: $9,000 (Deductible not Included) Individual: $7,500 Family: $15,000 (Deductible not Included)
Lifetime Maximum $7,000,000 In and Out-of-Network combined $7,000,000 In and Out-of-Network combined
Office Visits $30 Primary $50 Specialist 50%
Prescription Drugs Generic: $15 Brand: $40 Non-Formulary Brand: $60 ($500 Brand Deductible, see brochure for details) Not Covered
Laboratory and Radiology 25% 50%
Annual Physical Exam $25/$75 Co-Pay at HealthyCheck Centers for Basic/Premium Screening; $30 for members enrolled 6+ months 50%
Annual OB-GYN Exam $30 (See Brochure for complete details) 50%
Well Baby Care $30 (See Brochure for complete details) 50%
Outpatient Surgery 25% 50%
Emergency Room 25% 25%
Ambulance Ground and Air: 25% ($3,000/trip) Ground and Air: 50% ($3,000/trip)
Home Health Care 25% (60 visits/year each visit 4 hrs or less; In and Out-of-Network combined) 50% (60 visits/year each visit 4 hrs or less; In and Out-of-Network combined)
Mental Health Services - Outpatient 25% (48 days/member/calendar year; In and Out-of-Network combined) 50% (48 days/member/calendar year; In and Out-of-Network combined)
Chiropractic Care 25% (24 visits/year; In and Out-of-Network combined) 50% (24 visits/year; In and Out-of-Network combined)
Acupuncture / Acupressure See Brochure See Brochure
Inpatient Hospital 25% 50%
Maternity Care Covered Covered
Mental Health - Inpatient 25% (30 days/member/calendar year; In and Out-of-Network combined) 50% (30 days/member/calendar year; In and Out-of-Network combined)
Chemical Dependency 25% (30 days/member/calendar year; In and Out-of-Network combined) 50% (30 days/member/calendar year; In and Out-of-Network combined)

 

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.

 

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