Anthem Anthem Gold DirectAccess - ccac (Ohio)

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Company Anthem Blue Cross and Blue Shield
Plan Year 2014
State Ohio
Metal Tier Gold
Plan Type PPO
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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) $1,250
Deductible (Family) $2,500
Coinsurance $0
Out of Pocket Maximum (Individual) $5,000
Out of Pocket Maximum (Family) $10,000

Doctors Visits

Primary Care Visit $30
Specialist Visit No Charge
In Patient Hospital Services $500 Copay per Stay and 10% Coin
Emergency Room Services $200 Copay before deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) $0
Laboratory Outpatient and Professional Services $0
X-ray and Diagnostic Imaging $0


Mental / Behavioral Health $0
Rehabilitative Speech Therapy $0
Rehabilitative Occupational & Physical Therapy $0
Outpatient Facility $0
Outpatient Surgery $0

Prescription Drugs

Generic Rx $15
Preferred Brand Rx $40
Non Preferred Brand Rx No Charge
Specialty Drugs No Charge

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