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. Gold PPO Plan Summary of Benefits and Coverage

Anthem Blue Cross Gold Plan
In-NetworkOut-of-Network
Calendar Year Deductible
Individual$250$500
Family$750$1500
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
Individual$5,000$10,000
Family$10,000$30,000
Coinsurance/CopaysYou PayYou Pay
Preventive Care$050%*
Primary Care Physician$2550%*
Specialist$4550%*
Urgent Care20%*50%*
Emergency Room20%*20%*
Inpatient Hospital20%*50%*
Mental Health & Substance AbuseYou PayYou Pay
Inpatient20%*50%*
Outpatient$25$25
Pharmacy Retail Rx (up to 30-day supply)You Pay
PreventiveN/A
Generic$10
Preferred Brand$30
Specialty - Non PrudentRx$50
Specialty - PrudentRx$0 cost of share to member if enrolled. If not enrolled 30% coinsurance*
Specialty$50
Mail Order Rx (up to 90-day supply)You Pay
PreventiveN/A
Generic$20
Preferred Brand$60
Non-Preferred Brand$100
Specialty - Non PrudentRx$50
Specialty - PrudentRx$0 cost of share to member if enrolled. If not enrolled 30% coinsurance*
*Copay/cost share applies after plan deductible is met.
*For coverage types other than Employee Only, the deductible will automatically default to the family deductible.