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

Plan Name: Blue Access Value

Plan Type: PPO

Annual Out-of-Pocket Maximum: $14,000 Individual/$30,000 Family

Annual Deductible: $10,000 Individual/$30,000 Family

Office Visits: You pay $35 copay for visits 1 & 2, no deductible. (Copay applies to office visit charge only) 3+ visits, not covered. 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%, no deductible. $300 maximum per calendar year, network and non-network combined. Preventive services are excluded from the $300 limit 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

$15 Prescription: Not covered

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 Economy
• 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