Premier 5000 1 Member

The Premier 5000 1 Member plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: PPO

Deductible: $5,000

In-Patient Hospital Co-Payment/Coinsurance: 25%

Prescription Drug Coverage (Out Patient): Yes

Maternity Coverage Included: Yes

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Premier 5000 1 Member Summary:

	In Network	Out of Network
Annual Deductible	Individual: $5,000 Family: $10,000	Individual: $5,000 Family: $10,000
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.