Anthem Blue Cross and Blue Shield of Wisconsin Blue Preferred Plus 80 Plan Information

Plan Name: Blue Preferred Plus 80

Plan Type: PPO

Annual Out-of-Pocket Maximum: $10,500 Individual/$22,500 Family

Annual Deductible: $7,500 Individual/$22,500 Family

Office Visits: You pay $35 copayment for office visit charge, no deductible. You pay 20% for other office services; subject to annual deductible

Coinsurance (Network/Non-Network): You pay 20%/40%; subject to annual deductible

Hospital Inpatient/Outpatient: You pay 20%; subject to annual deductible

Emergency Services: You pay 20%; subject to annual deductible

Urgent Care (in Urgent Care Center): You pay 20%; subject to annual deductible

Preventive Care: You pay $35 copay for office visit charge. You pay 10% for other services; subject to annual deductible

Diagnostic Services: You pay 20%; subject to annual deductible

Ambulance Services: You pay 20%; subject to annual deductible

Mental Health: Not Covered

Financial/Tax Incentive: No

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

Drug Coverage: You pay $15 Generic (Tier 1)/$30 Formulary Brand after $500 drug deductible (Tier 2)/$60 Non-Formulary Brand after $500 drug deductible (Tier 3)/25% self-injectibles (Tier 4)

Prescription Drug Copay: Yes

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

• Blue Access Value
• 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 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