Anthem Blue Cross and Blue Shield of Ohio Blue Access Plan 1 20 Coinsurance Plan Information

Plan Name: Blue Access Plan 1 20 Coinsurance

Plan Type: PPO

Physician Choice: Yes

Annual Out-of-Pocket Maximum: $2,500 Individual

Annual Deductible: $500 Individual

Office Visits: Network you pay 20%; subject to calendar-year deductible. Non-network you pay 50%; subject to calendar-year deductible

Coinsurance (Network/Non-Network): You pay 20%/50%

Hospital Inpatient/Outpatient: You pay 20%/50%; subject to calendar-year deductible

Emergency Services: You pay 20%; subject to calendar-year deductible

Urgent Care (in Urgent Care Center): You pay 20%; subject to calendar-year deductible

Maternity (Network/Non-Network): Not Covered

Preventive Care: Network you pay 20%; subject to calendar-year deductible.Non-network you pay 50%; subject to calendar-year deductible

Ambulance Services: You pay 20%; subject to calendar-year deductible.

Mental Health: Network you pay 20%; subject to calendar-year deductible.Non-network you pay 50%; subject to calendar-year deductible

Drug Benefits: Generic Formulary and Generic Non-Formulary: You pay $15 per prescription; Copayment does not apply to deductible or out-of-pocket maximums. Brand-name, Mail Service, and Non-network drugs are 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
• Blue Access Economy Plan 30 Coinsurance
• 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 2 20 Coinsurance
• Blue Access Plan 2 20 Coinsurance