Anthem BlueCross BlueShield

Anthem Gold X HMO 1200

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,200 Family: $2,400 Per Person: $1,200
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: First 2 visits at $35 Copay with deductible, <br> 30% Coinsurance after deductible
Specialist	Standard: 30% Coinsurance after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $40 Copay
Non Preferred Brand Drugs	Standard: 30% Coinsurance after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 30% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $1000 Copay per stay with deductible<br>30% Coinsurance after deductible
Inpatient Services	Standard: 30% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500 Copay with deductible<br>30% Coinsurance after deductible

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