Plan Details
Plan Name	Anthem PPO
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$500	$1,000
Annual Deductible/Family	$1,000	$2,000
Coinsurance	10%	50%
Office Visit/Exam	$20	50% after deductible
Outpatient Specialist Visit	$30	50% after deductible
Annual Out-of-Pocket Limit/Individual	$2,500	$5,000
Annual Out-of-Pocket Limit/Family	$5,000	$10,000
Preventive Care	0%	50% after deductible
Inpatient Hospitalization	10% after deductible	50% after deductible
Surgical Services Outpatient Facility Charge	10% after deductible	50% after deductible
Emergency Room	10% after deductible	10% after deductible
Urgent Care Facility	10% after deductible	50% after deductible
Prescription Drug Deductible	$0	$0
Prescription Drugs - Generic	$10	30%
Prescription Drugs - Brand (Formulary/Preferred)	$30	30%
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50	30%
Prescription Drugs - Specialty	30% up to $100	Not Covered
Chiropractic Services	$30	50% after deductible
Acupuncture	$30	50% after deductible