Anthem Blue Cross and Blue Shield of Missouri Blue Access Choice 100 Plan Information

Plan Name: Blue Access Choice 100

Plan Type: PPO

Annual Out-of-Pocket Maximum: $1,000 Individual/$3,000 Family

Annual Deductible: $1,000 Individual/$3,000 Family

Office Visits: You pay $25 copay for office visit charge, no deductible. You pay 0% for other office services; subject to annual deductible

Coinsurance (Network/Non-Network): You pay 0%/40%; subject to annual deductible

Hospital Inpatient/Outpatient: You pay 0%; subject to annual deductible

Emergency Services: You pay 0%; subject to annual deductible

Urgent Care (in Urgent Care Center): You pay 0%; subject to annual deductible

Preventive Care: You pay $25 copay for office visit charge. You pay 0% for other services; subject to annual deductible

Diagnostic Services: You pay 0%; subject to annual deductible

Ambulance Services: You pay 0%; subject to annual deductible

Mental Health: You pay $25 copay for office visits. You pay 0% for inpatient care; subject to annual deductible

Financial/Tax Incentive: No

Maternity Coverage: Not covered, except covered for complications of pregnancy

Drug Coverage: You pay $15 Generic (Tier 1)/$30 Formulary Brand after $500 drug deductible (Tier 2)/$60 Non-Formulary Brand after $500 drug deductible (Tier 3)/25% self-injectibles (Tier 4)

Prescription Drug Copay: Yes

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

• Blue Access Choice Value
• Blue Access Value
• Blue Access Choice Economy
• Blue Access Choice 80
• Lumenos Health Savings Account Plan 1
• Lumenos Health Incentive Account Plan 1
• Lumenos Health Incentive Account Plus Plan 1
• Lumenos Health Savings Account Plan 2
• Blue Access 90
• Blue Access 80
• Blue Access Choice 90
• Blue Access 100
• Lumenos Health Incentive Account Plus Plan 2
• Blue Preferred HMO 90