Anthem Blue Cross and Blue Shield of Ohio Blue Access Economy Plan 30 Coinsurance Plan Information

Plan Name: Blue Access Economy Plan 30 Coinsurance

Plan Type: PPO

Physician Choice: Yes

Annual Out-of-Pocket Maximum: $4,500 Individual

Annual Deductible: $1,500 Individual

Office Visits: Network you pay $30 copay for the first 3 office visits per person per calendar year; 4+ office visits you pay 30% after deductible. You pay 30% for other office services. Non-network you pay 50%; subject to calendar-year deductible

Coinsurance (Network/Non-Network): You pay 30%/50%

Hospital Inpatient/Outpatient: You pay 30%/50%; subject to calendar-year deductible.

Emergency Services: You pay 30%; subject to calendar-year deductible

Urgent Care (in Urgent Care Center): You pay 30%; subject to calendar-year deductible

Maternity (Network/Non-Network): Not Covered

Preventive Care: For adults: Not covered, except Mammography and Pap Test. For Children: Birth to 12 months $500 maximun ;age 1-9 $150 maxium per year

Ambulance Services: You pay 30%; subject to calendar-year deductible

Mental Health: You pay 30%/50%; subject to calendar year deductible

Drug Benefits: Generic Formulary & Generic Non-formulary $15 per prescription. $500 maximum per person per calendar year, not subject to deductible. Brand-name Formulary, Brand Non-formulary, and Mail Service Not Covered

Financial/Tax Incentive: No

Prescription Drug Copay: Yes

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

• Blue Access Value Plan 30 Coinsurance
• Blue Access Value Plan 30 Coinsurance
• Lumenos Health Savings Account Plan 1
• Lumenos Health Incentive Account Plan 1
• Lumenos Health Incentive Account Plus Plan 1
• Blue Access Plan 1 20 Coinsurance
• Blue Access Value Plan 30 Coinsurance
• Blue Access Plan 3 0 Coinsurance
• Blue Access Value Plan 30 Coinsurance
• Lumenos Health Savings Account Plan 2
• Lumenos Health Incentive Account Plus Plan 1
• Blue Access Economy Plan 30 Coinsurance
• Blue Access Plan 1 20 Coinsurance
• Lumenos Health Incentive Account Plan 2
• Blue Access Plan 3 0 Coinsurance
• Lumenos Health Savings Account Plan 1
• Lumenos Health Incentive Account Plan 1
• Lumenos Health Incentive Account Plus Plan 2
• Lumenos Health Savings Account Plan 2
• Blue Access Plan 3 0 Coinsurance
• Blue Access Economy Plan 30 Coinsurance
• Lumenos Health Incentive Account Plus Plan 1
• Blue Access Plan 2 20 Coinsurance
• Lumenos Health Savings Account Plan 1
• Lumenos Health Incentive Account Plan 2
• Blue Access Plan 1 20 Coinsurance
• Blue Access Economy Plan 30 Coinsurance
• Lumenos Health Incentive Account Plan 1
• Blue Access Plan 2 20 Coinsurance
• Blue Access Plan 1 20 Coinsurance
• Blue Access Plan 2 20 Coinsurance
• Blue Access Plan 2 20 Coinsurance