Anthem BlueCross BlueShield

Gold HMO BlueCare Prime with Added Dental and Vision Benefits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $2,400 Family: $4,800 Per Person: $2,400
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.
Specialist	CoPay: $60.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply for Retail or 90 day supply for Home Delivery. Cost share shown is for a 30 day supply. Retail Tier 3 and Tier 4 fill coinsurance is limited to a specific maximum per prescription, depending on your specific plan.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Emergency Room copay is waived if directly admitted to the hospital.
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Limited reimbursement

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

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