Anthem Blue Cross Gold Plan

Medical Plan

Anthem Blue Cross Gold Plan

Although services are covered both in-network and out-of-network, your benefits are greater when you choose in-network providers. Benefit Tip: This plan features the lowest annual deductible of the Anthem Blue Cross plans in exchange for a higher premium from your paycheck.

Anthem Blue Cross Gold Plan
	In-Network	Out-of-Network
Calendar Year Deductible
Individual	$250	$250
Family	$750	$750
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
Individual	$5,000	$10,000
Family	$10,000	$30,000
Coinsurance	You Pay	You Pay
Preventive Care	$0	50%*
Primary Care Physician	$25	50%*
Specialist	$45	50%*
Urgent Care	20%*	50%*
Emergency Room	20%*	20%*
Inpatient Hospital	20%*	50%*
Mental Health & Substance Abuse	You Pay	You Pay
Inpatient	20%*	50%*
Outpatient	$25	$25
Pharmacy Retail RX (up to 30-day supply)	You Pay
Preventive	N/A
Generic	$10
Preferred Brand	$30
Non-Preferred Brand	$50
Specialty	$50
CVS Mail Order RX (up to 90-day supply)	You Pay
Preventive	N/A
Generic	$20
Preferred Brand	$60
Non-Preferred Brand	$100
Specialty (30-day supply only)	$50

*After deductible
**If the actual cost of the drug is less than the minimum, you pay the cost of the drug.

Medical Plan

Anthem Blue Cross Gold Plan

Anthem Blue Cross Gold Plan
	In-Network	Out-of-Network
Calendar Year Deductible
Individual	$250	$250
Family	$750	$750
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
Individual	$5,000	$10,000
Family	$10,000	$30,000
Coinsurance	You Pay	You Pay
Preventive Care	$0	50%*
Primary Care Physician	$25	50%*
Specialist	$45	50%*
Urgent Care	20%*	50%*
Emergency Room	20%*	20%*
Inpatient Hospital	20%*	50%*
Mental Health & Substance Abuse	You Pay	You Pay
Inpatient	20%*	50%*
Outpatient	$25	$25
Pharmacy Retail RX (up to 30-day supply)	You Pay
Preventive	N/A
Generic	$10
Preferred Brand	$30
Non-Preferred Brand	$50
Specialty	$50
CVS Mail Order RX (up to 90-day supply)	You Pay
Preventive	N/A
Generic	$20
Preferred Brand	$60
Non-Preferred Brand	$100
Specialty (30-day supply only)	$50

*After deductible
**If the actual cost of the drug is less than the minimum, you pay the cost of the drug.

Sydney Health App

Manage your benefits, claims, and more with the Anthem Blue Cross Sydney Health App. Download from the App Store or Google Play.

Part-time and Temporary employees are eligible for a limited subset of benefits. Union employees: refer to your collective bargaining agreement for your benefits eligibility.