Anthem Blue Cross and Blue Shield of New Hampshire Blue Direct 5000 Plan Information
Plan Name:Blue Direct 5000
Provider/ Facilities:In-Network:PPO Network of Providers, Out-of-Network:Use any Provider
Deductible (Individual/Family):In-Network:$5,000/$15,000, Out-of-Network:$7,500/$22,500
Lifetime Maximum Benefit:In-Network:Total program maximum is $2,000,000.
Out of network benefits maximum $250,000 per calendar year (counts towards program maximum), Out-of-Network:Total program maximum is $2,000,000.
Out of network benefits maximum $250,000 per calendar year (counts towards program maximum)
Prescription Drug:In-Network:$100 deductible per member per calendar year.
(Deductible does not apply to generic drugs.)
Then:
$10copay/ generic
$25 copay/formulary brand
$40 copay/non-formulary brand
$2,000 maximum per member per calendar year., Out-of-Network:Not Covered
Outpatient Services:In-Network:Subject to: $5000 deductible per member, no more than $15,000 per family per calendar year
And
20% coinsurance up to $1000 per member, no more than $3000 per family per calendar year, Out-of-Network:Subject to: $7500 deductible per member, no more than $22,500 per family per calendar year and 50% coinsurance up to $1000 per member, no more than $3000 per family per calendar year
Preventive Care:In-Network:Covered in Full -
Immunization, lead screening, PSA, Mammogram & Pap Smear
Subject to: $5000 deductible per member, no more than $15,000 per family per calendar year
And
20% coinsurance up to $1000 per member, no more than $3000 per family per calendar year, Out-of-Network:Covered in Full -
Immunization, lead screening, PSA, Mammogram & Pap Smear
Subject to: $7500 deductible per member, no more than $22,500 per family per calendar year
and 50% coinsurance up to $1000 per member, no more than $3000 per family per calendar year
Hospital Inpatient Services:In-Network:Semi-private room & board subject to
$5000 Deductible per member, no more than $15,000 per family per calendar year an 20% coinsurance up to $1000 per member, no more than $3000 per family per calendar year, Out-of-Network:Subject to: $7500 deductible per member, no more than $22,500 per family per calendar year
and 50% coinsurance up to $1000 per member, no more than $3000 per family per calendar year
Emergency Care:In-Network:$100 per visit subject to $5000 Deductible per member, no more than $15,000 per family per calendar year and 20% coinsurance up to $1000 per member, no more than $3000 per family per calendar year, Out-of-Network:Same as In-Network Benefits
Durable Medical Equipment (DME):In-Network:$100 deductible and 30% coinsurance up to $3000 per member per calendar year, Out-of-Network:Same as In-Network Benefits
Other Anthem Blue Cross and Blue Shield of New Hampshire health insurance plans:
