Anthem Blue Cross and Blue Shield of Wisconsin Blue Access Economy Plan Information

Plan Name: Blue Access Economy

Plan Type: PPO

Annual Out-of-Pocket Maximum: $9,000 Individual/$18,000 Family

Annual Deductible: $5,000 Individual/$15,000 Family

Office Visits: You pay $35 copay for first 3 visits, no deductible. (Copay applies to office visit charge only) 4+ visits you pay 30%; subject to annual deductible. You pay 30% for other office services; subject to annual deductible Coinsurance (Network/Non-Network): You pay 30%/50%; subject to annual deductible

Hospital Inpatient/Outpatient: You pay 30%; subject to annual deductible

Emergency Services: You pay 30%; subject to annual deductible

Urgent Care (in Urgent Care Center): You pay 30%; subject to annual deductible

Preventive Care: You pay 30%;subject to annual deductible (Routine pap smear, annual mammogram, colorectal cancer screening and PSA screening). Other preventive services are not covered Diagnostic Services: You pay 30%; subject to annual deductible

Ambulance Services: You pay 30%; subject to annual deductible

Mental Health: Not Covered

Financial/Tax Incentive: No

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

Drug Coverage: Drug benefits are not covered. You receive drug discounts

Prescription Drug Copay: Yes

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

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