Blue Preferred 1000 80/20
Benefits at a Glance
Blue
Cross And Blue Shield
DEDUCTIBLE: applicable only to specified services (Per calendar year, aggregate deductible for family)
In-Network: Individual: $1,000, Family $3,000; Out-of-Network: Individual: $2,000; Family $6,000
| Services | In-network after Deductible | Out-of-Network after Deductible | Additional Information |
| Ambulance Service 1000-35-80/50
|
Ground
Air Services Services 80% 80%
|
Ground
Air Services
Services 80% 80%
|
Benefits are paid for medically necessary ground or air ambulance transportation. Ground Service are limited to a maximum benefit of $500 per trip. Air Services are limited to maximum benefit of $5,000 per trip. |
| Alcohol & Drug Abuse 1000-35-80/50 |
Inpatient Outpatient 80% 80%
|
Inpatient Outpatient 50% 50%
|
Benefits are paid for medically necessary treatment for detoxification up $1,500; inpatient or out rehabilitation $9,000; and counseling $2,500 per member per calendar year. |
| Chemotherapy, Hemodialysis, and Radiation Therapy Inpatient or Outpatient 1000-35-80/50 |
80% |
50% |
|
| Diagnostic Services, Laboratory, Pathology, and X-ray Inpatient or Outpatient 1000-35-80/50 |
80% | 50% | Services billed by a hospital are included in the hospital inpatient or outpatient benefits. |
| Emergency Care 1000-35-80/50 |
80% | 50% | |
| Home Health Care 1000-35-80/50 |
80% | 50% | Benefits are limited to 60 visits per calendar year |
| Hospice Care
1000-35-80/50 |
80% | 50% | Benefit period of three months up to maximum of two additional benefit periods, subject to a $5,000 payment limit per benefit period, payable at $55 per day |
| Hospital Care Inpatient/outpatient Surgery and Outpatient Nonemergency 1000-35-80/50 |
80% | 50% | |
| Maternity Care 1000-35-80/50 |
Inpatient outpatient 80% $35 copay per visit |
Inpatient outpatient 50% 50%
|
Benefits are paid for complications of pregnancy only. Routine maternity care is not covered. |
| Severe Mental Illness 1000-35-80/50 |
Inpatient outpatient 70% 70%
|
Inpatient outpatient 50% 50%
|
Benefits are paid up to 40 inpatient days, 80
partial days (combined).
Benefits are paid up to 40 visits per calendar year. |
| Physical Rehabilitation (physical, occupational, and
speech therapy) Inpatient and outpatient 1000-35-80/50 |
80% | 50% | Benefits are paid up to 45 days per year. Benefits are paid up to 12 visits for occupational therapy and 12 visits for speech therapy per calendar year. |
| Physician Visits Inpatient
outpatient Outpatient-urgent 1000-35-80/50 |
80%
$35 copay per visit $70 copay per visit |
50% 50% 50% |
|
| Preventive Care A. Children - routine child exam to age 13 and immunizations to age 13 B. Adults- -routine pap smear -routine mammography -routine prostate screening |
80% not subject to deductible 80% not subject to deductible $75 maximum payment for laboratory charges $85 maximum payment $65 maximum payment |
50%
50%
$85 maximum payment $65 maximum payment |
Annual pap smears for 18 years or older. One screening mammogram for women between 35 and 40; and annual mammogram for women over 40 years of age. One yearly prostate screening for men 50 years of age and older, and in high-risk men 40 years of age and older. All maximum payments are combined from Preferred and Non-Preferred providers. |
| Spinal Manipulations 1000-35-80/50 |
80% | 50% | Benefits are limited to a maximum payment of $200 per calendar year per member. |
| Supplies, Equipment, and Appliances (DME) Inpatient/Outpatient 1000-35-80/50 |
80% | 50% | |
| Temporomandibular Joint Syndrome (TMJ) 1000-35-80/50 |
50% | 50% | Benefits are paid up to $4,000 lifetime maximum. |
| Outpatient Prescription Drugs: 1000-35-80/50 |
Participating Pharmacy: Generic $15 copayment ; Brand Formulary $40 copayment; Non-Formulary $60 copayment (up to a 34 -day supply) | Mail Order: Participating Pharmacy Generic $30 copayment: Brand Formulary $80 copayment; Non-Formulary $120 copayment (up to a 90-day supply | |
| Dependent Eligibility: | The end of the month in which the employee's dependent child becomes age 19 or 24 if financially dependent upon the subscriber. | ||
| Maximum out-of-pocket expense amount:
1000-35-80/50 |
In-Network: Individual you pay 20% of the allowable charges up to $3,000 plus deductible and copayments. Family: you pay 20% of the allowable charges up to $6,000 plus deductible and copayments. | Out-of-network:
Individual you pay 50% of the allowable charges up
to $6,000 plus deductible and copayments. Family:
you pay 50% of the allowable charges up to $12,000 plus deductible and
copayments.
|
Allowable charges means the contracted amount for Preferred Providers or the Maximum Benefit allowance for Non-Preferred Providers. |
| Lifetime Maximum Benefits: 1000-35-80/50 |
$2,000,000 per member | $2,000,000 per member | |
| Vision Benefits | Click Here | ||
| Dental | Click Here |
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Important:
This plan overview is intended to be a brief outline of
coverage. All terms and conditions of coverage, including
benefits and exclusions, are contained in the Certificate,
which shall control in the event of a conflict with this
overview.
These programs may be terminated or modified at the discretion
of Anthem Blue Cross and Blue Shield.
The brief description of the plans provided through Anthem Blue Cross and Blue Shield are a general guide for more detailed description please contact Denise Brown about coverage, benefits, limitations, exclusions and any additional information about cost and enrollment.
Forging a New Path to Better Health Care,
Denise Brown Owner/Broker
Direct Health & Life of Nevada
Authorized Nevada Agent
Phone: (702) 349-7579
email: dee2000@cox.net