Anthem Anthem Blue Cross and Blue Shield Gold DirectAccess, a Multi-State Plan (New Hampshire)

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Company Anthem Blue Cross and Blue Shield
Plan Year 2014
State New Hampshire
Metal Tier Gold
Plan Type HMO
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $1,000
Deductible (Family) $2,000
Coinsurance 10%
Out of Pocket Maximum (Individual) $3,500
Out of Pocket Maximum (Family) $7,000

Doctors Visits

Primary Care Visit $30
Specialist Visit 10% Coinsurance after deductible
In Patient Hospital Services $500 Copay per Stay and 10% Coin
Emergency Room Services $200 Copay before deductible and

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 10% coinsurance
Laboratory Outpatient and Professional Services 10% coinsurance
X-ray and Diagnostic Imaging 10% coinsurance


Mental / Behavioral Health 10% coinsurance
Rehabilitative Speech Therapy 10% coinsurance
Rehabilitative Occupational & Physical Therapy 10% coinsurance
Outpatient Facility 10% coinsurance
Outpatient Surgery 10% coinsurance

Prescription Drugs

Generic Rx $15
Preferred Brand Rx $40
Non Preferred Brand Rx 10% Coinsurance after deductible
Specialty Drugs 10% Coinsurance after deductible

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