$4,500 annual out-of-pocket maximum (the most you will have to pay) (In-network only and in addition to brand-name/specialty drug deductible)9

Specialty: Not covered

1 Once a member meets their single deductible, their deductible is satisfied. After one family member’s single deductible is satisfied, the family maximum can be met by two or more family members.

2 Excludes non-participating charges in excess of the Anthem Blue Cross negotiated fee and non-participating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and non-participating providers apply to out-of-pocket maximum except where specifically noted in the policy.

3 Applies to first three preventive care visits and/or doctors’ office visits.

4 Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient.

5 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer.

6 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s brand-name deductible.

7 Not to exceed $500 maximum (the most you would need to pay) per brand-name prescription.

8 Specialty drugs include injected, infused, oral and inhaled medications that generally need to be closely monitored by your doctor. These drugs tend to be higher in cost and often require special handling and ordering.

9 The annual brand-name/specialty drug deductible and annual brand-name/specialty drug out of-pocket maximum are separate from the annual medical deductible and annual medical out of maximum. They are not combined for in-network and out-of-network.