Anthem BlueCross

Platinum 90 HMO

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Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,500 Family: $9,000 Per Person: $4,500

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non Preferred Brand Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 10.00% Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Inpatient Coverage

Hospital Services	CoPay: $250.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient Services	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.

Emergency and Urgent Care

Emergency Room	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Urgent Care Facility	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity

Labor and Delivery Hospital Stay	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 1 Limit Unit : Visit(s) per 6 Months Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Health care service plans provided by Anthem Blue Cross. Insurance policies provided by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.®The Blue Cross name and symbol are registered marks of the Blue Cross Association.

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