Anthem Blue Cross and Blue Shield of Colorado RightPlan PPO 40 Comprehensive RX Plan Information

Plan Name: RightPlan PPO 40 Comprehensive RX

Plan Type: PPO

Financial/Tax Incentive: No

Physician Choice: You choose specialist(s)

Annual Deductible: None

Coinsurance: You pay 40% in-network/50% out-of-network

Annual Out-of-Pocket Maximum (includes deductible): $3,500 in-network and $10,000 out-of-network

Lifetime Maximum: $5,000,000 per person

Office Visits: You pay $40

Professional Service Includes X-ray and lab charges: You pay 40%

Emergency Care: You pay $100, plus 40%

Ambulance: You pay $100

Hospital Inpatient Services: You pay $500 per day up to four days, plus 40%

Outpatient Services: You pay $500, plus 40%

Preventive Care- Children: You pay $40, plus 40% (through age 12)

Preventive Care- Adult: You pay $40, plus 40% for routine pap smear, $75 max for lab You pay $0 for routine mammogram You pay $0 for routine prostate

Prescription Drug Benefits: You pay $10 Generic You pay $30 Brand, $500 Brand Deductible You pay 50% Non-formulary

Maternity: Not Covered

Significant Additional Services: Discounts for products and services that promote health with SpecialOffers@Anthem

Other Anthem Blue Cross and Blue Shield of Colorado health insurance plans:

• Lumenos HSA 5000 10000 100
• Lumenos HIA 5000 10000 100
• Lumenos HSA 3000 6000 80
• BluePreferred For Individuals 3000 10000
• Lumenos HIA 3000 6000 80
• Lumenos HSA 2500 5000 80
• Lumenos HIA 2500 5000 80
• Lumenos HSA 3000 6000 100
• Lumenos HSA 1500 3000 70
• Lumenos HIA 3000 6000 100
• Lumenos HIA 1500 3000 70
• Lumenos HSA 2500 5000 100
• Lumenos HIA 2500 5000 100
• Lumenos HIA Plus 5000 10000 100
• Lumenos HIA Plus 3000 6000 80
• Lumenos HSA 1500 3000 100
• Lumenos HIA 1500 3000 100
• Lumenos HIA Plus 2500 5000 80
• BluePreferred For Individuals 2000 10000
• Lumenos HIA Plus 3000 6000 100
• RightPlan PPO 40 no RX
• BluePreferred For Individuals 2000 5000
• Lumenos HIA Plus 2500 5000 100
• RightPlan PPO 40 Generic RX
• BluePreferred For Individuals 1000 10000
• BluePreferred For Individuals 1000 5000
• BluePreferred For Individuals 500 10000
• BluePreferred For Individuals 500 5000