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Medical Plan Choices | Outside California 8

Medical Plans Available Outside California

Plan Anthem Blue Cross
Features Exclusive Classic (EPO) Plan
In-Network 1 Out-of-Network 1
Annual Deductible None Individual: $3,000
Family: $6,000

Annual Out-of-Pocket Maximum Individual: $2,500 Individual: $9,000
Family: $5,000 Family: $18,000

Lifetime Maximum Benefits Unlimited
Medical Services
Doctor’s Office Visits $20 copay Covered at 50%
Specialist: $40 copay

Preventive Care Covered at 100% Covered at 50%
Physical Therapy $20 copay Covered at 50%
Alternative Care
Chiropractic $20 copay 2 Covered at 50% 2

Acupuncture $20 copay 3 Covered at 50% 3
Prescription Drugs
Retail Pharmacy Tier 1: $10 copay Covered at 50% of maximum allowed
(30-Day Supply) Tier 2: $30 copay amount after copay
Tier 3: $50 copay
Tier 4: Covered at 70%;
$250 copay max
Mail Order Not covered
(90-Day Supply) 4 Tier 1: $25 copay
Tier 2: $90 copay
Tier 3: $150 copay
Tier 4: Covered at 70%;
$250 copay max
Hospital Services
Room & Board/Surgeon’s Fees/ $250 copay Covered at 50%;
Maternity Delivery limited to $1,000/day
Emergency Care $100 copay; waived if admitted

Mental Health/
Substance Abuse Services
Outpatient $20 copay Covered at 50%

Inpatient $250 copay Covered at 50%;
limited to $1,000/day

1 Payable at the negotiated fee rate and subject to deductible.
2 Limited to 30 visits per calendar year.
3 Limited to 20 visits per calendar year.
4 Limited to 30-day supply for Tier 4 prescriptions.