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

Plan Name: Blue Access Value Plan 30 Coinsurance

Plan Type: PPO

Physician Choice: Yes

Annual Out-of-Pocket Maximum: $5,000 Individual

Annual Deductible: $2,000 Individual

Office Visits: Visits 1 & 2, member pays $30 copayment, no deductible. (Copayment only applies to office visit charge) Visits 3+, Not Covered {Other office services subject to deductible and coinsurance}

Coinsurance (Network/Non-Network): You pay 30%/40%

Hospital Inpatient/Outpatient: You pay 30%/40%; subject to calendar-year deductible

Emergency Services: You pay 30%; subject to calendar-year deductible (additional $60 copayment if not admitted)

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

Maternity (Network/Non-Network): Not Covered, except for complications of pregnancy only

Preventive Care: You pay 30%/40%; subject to calendar-year deductible. Adult: (Routine Pap smear, annual mammogram, colorectal cancer & PSA screening only). Well Child & Immunizations (Birth to 12 months; $500 maximum, age 1 through 8, $150 maximum/year)

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

Mental Health: You pay 30%/40%; subject to calendar-year deductible

Drug Benefits: Maximum payment by Anthem of $500 per calendar year. Generic drugs - Member pays a $10 copayment per 30 day supply. Brand name formulary drugs - there is a $200 deductible per member per year, then the member pays a $25 copayment per 30 day supply

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
• 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 1 20 Coinsurance
• Blue Access Plan 2 20 Coinsurance
• Blue Access Plan 2 20 Coinsurance