Santen 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)
- Anthem Blue Cross HMO (California Only)
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 | $2,500 | $500 | $1,500 | |
| Family | $5,000 | $1,500 | $4,500 | |
| For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. | ||||
| Out-of-Pocket Maximum | ||||
| Individual (includes deductible) | $2,500 | $5,000 | $3,500 | $10,500 |
| Family (includes deductible) | $5,000 | $10,000 | $7,000 | $21,000 |
| Physician Services | ||||
| Office Visit | No charge after deductible | 30% after deductible | $20 primary care $40 specialist | 30% after deductible |
| Preventive Care | No charge (deductible waived) | 30% after deductible | No charge (deductible waived) | 30% after deductible |
| Diagnostic Lab and X-Ray | No charge after deductible | 30% after deductible | 10% after deductible | 30% after deductible |
| Complex Lab and X-Ray | No charge after deductible | 30% after deductible | 10% after deductible | 30% after deductible |
| Hospital Services | ||||
| Inpatient (per admission) | No charge after deductible | 30% after deductible | 10% after deductible | 30% after deductible |
| Outpatient Surgery | No charge after deductible | 30% after deductible | 10% after deductible | 30% after deductible |
| Emergency Treatment | ||||
| Emergency Room (waived if admitted) | No charge after deductible | $150 copay then 10% | ||
| Retail Prescriptions¹ (30-day supply) | ||||
| Tier 1 Lower Cost Generic/Generic | No charge after deductible | 30% + amount over max allowable charge | $5 / $20 | 50% to $250 max |
| Tier 2 | $40 | |||
| Tier 3 | $60 | |||
| Tier 4 | 30% to $250 max | |||
| Mail-Order Prescriptions¹ (90-day supply) | ||||
| Tier 1 Lower Cost Generic/Generic | No charge after deductible | Not covered | $12.50 / $50 | Not covered |
| Tier 2 | $120 | |||
| Tier 3 | $180 | |||
| Tier 4 | 30% to $250 max | |||
1 For prescription drug formulary information, visit the carrier website or contact Members Services via the toll-free number on your ID card.
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California Only Plan
| Anthem Blue Cross HMO (California Only) | |
|---|---|
| Key Features | In-Network |
| Annual Calendar Year Deductible | |
| Individual | None |
| Family | None |
| Not applicable | |
| Out-of-Pocket Maximum | |
| Individual (includes deductible) | $2,000 |
| Family (includes deductible) | $4,000 |
| Physician Services | |
| Office Visit | $20 |
| Preventive Care | No charge |
| Diagnostic Lab and X-Ray | No charge |
| Complex Lab and X-Ray | $100 |
| Hospital Services | |
| Inpatient (per admission) | $250 |
| Outpatient Surgery | $125 |
| Emergency Treatment | |
| Emergency Room (waived if admitted) | $100 |
| Retail Prescriptions¹ (30-day supply) | |
| Tier 1 Lower Cost Generic/Generic | $5 / $15 |
| Tier 2 | $30 |
| Tier 3 | $50 |
| Tier 4 | 30% to $250 max |
| Mail-Order Prescriptions¹ (90-day supply) | |
| Tier 1 Lower Cost Generic/Generic | $12.50 / $37.50 |
| Tier 2 | $90 |
| Tier 3 | $150 |
| Tier 4 | 30% to $250 max |
1 For prescription drug formulary information, visit the carrier website or contact Members Services via the toll-free number on your ID card.
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