Anthem Blue Cross and Blue Shield of Kentucky Blue Access Plan 3 0 Coinsurance Plan Information

Plan Name: Blue Access Plan 3 0 Coinsurance

Plan Type: PPO

Physician Choice: Yes

Annual Out-of-Pocket Maximum: $10,000 Individual

Annual Deductible: $10,000 Individual

Office Visits: You pay 0%/50%; subject to calendar-year deductible

Coinsurance (Network/Non-Network): You pay 0%/50%

Hospital Inpatient/Outpatient: Network you pay 0%; subject to calendar-year deductible. Non-network you pay 50%; subject to calendar-year deductible

Emergency Services: You pay 0%; subject to calendar-year deductible.

Urgent Care (in Urgent Care Center): You pay 0%; subject to calendar-year deductible

Maternity (Network/Non-Network): Not Covered

Preventive Care: Network you pay 0%; subject to calendar-year deductible. Non-network you pay 50%; subject to calendar-year deductible

Ambulance Services: You pay 0%; subject to calendar-year deductible.

Mental Health: Network you pay 0%; subject to calendar-year deductible. Non-network you pay 50%; subject to calendar-year deductible

Drug Benefits: Network Retail - Tier 1/$15, Tier 2/$30, Tier 3/$60, Tier 4 25% up to $2500 out-of-pocket maximum for Retail and Mail order combined.

Financial/Tax Incentive: No

Extended Mental Health: Not Covered

Prescription Drug Copay: Yes

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

• Blue Access Value Plan 30 Coinsurance
• Blue Access Plan 1 20 Coinsurance
• Lumenos Health Savings Account Plan 1
• Lumenos Health Incentive Account Plan 1
• Lumenos Health Incentive Account Plus Plan 1
• Blue Access Economy Plan 30 Coinsurance
• Lumenos Health Savings Account Plan 2
• Blue Access Plan 2 20 Coinsurance
• Lumenos Health Incentive Account Plus Plan 2