![]() You’ll typically pay more and may need to file a claim for payment. Health care professionals, hospitals, clinics, and labs that do not belong to the Anthem Blue Cross Prudent Buyer network. ![]() UC SHIP contracts with Anthem Blue Cross to provide access to its extensive network of hospitals and providers, including UC Family facilities and provider groups. You’ll usually pay less when you use a network healthcare provider. A group of healthcare providers and facilities-including doctors, hospitals, and labs-that contract with your healthcare plan to provide services at negotiated discount rates.After you meet the maximum, UC SHIP covers 100% of all eligible costs for the rest of the plan year. The maximum amount of money you’ll have to pay for health care in a year.If you receive services from an out-of-network provider, the provider will bill you the difference, if any, between their charges and the maximum allowed amount. It is the claims administrator’s payment toward the services billed by your provider, combined with any deductible or coinsurance you may owe. The total reimbursement payable under your plan for covered services you receive from in-network and out-of-network providers.An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm or death.The amount you have to pay toward medical costs before UC SHIP starts paying part of the bill.For example, you might pay 20% of the cost for a particular service, and the insurance company or plan will pick up the tab for the remaining 80%. The slice of a medical service you’re responsible for.For example, you might pay a $15 copay to see a primary care doctor or specialist. The flat fee you pay for covered services, usually due at the time you receive care.$50 copay per visit for the first 2 visits, then deductible and 30% coinsuranceĭeductible, then $400 copay and 50% coinsuranceĭeductible, then $75 copay and 35% coinsuranceĭeductible, then $50 copay and 30% coinsuranceĮmergency room care (Copay waived if admitted into the hospital from the emergency room. $45 copay per visit for the first 2 visits, then deductible and 20% coinsurance Level 1 / Level 2 Pharmacy Tier 1, 2, 3, 4: Medical deductible appliesĬoinsurance (percentage may vary for some covered services) $50 copay per visit for the first 2 visits, then deductible and 40% coinsuranceĭeductible, then $50 copay and 40% coinsuranceĭeductible, then $75 copay and 50% coinsuranceĭeductible, then $50 copay and 20% coinsuranceĭeductible, then $500 copay and 40% coinsuranceĭeductible, then $500 copay and 20% coinsuranceĭeductible, then $1,500 copay and 50% coinsurance Individual Out-of-Pocket Maximum An out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care servicesĬoinsurance What % you pay after your deductible has been met and before your out of pocket max (percentage may vary for some covered services) Office visit: chiropractic (limits apply)Īnthem Bronze Pathway X 20% for HSA (1GEW) Physical and occupational therapy (limits apply) Retail pharmacy tier 4: level 1 / level 2 Retail pharmacy tier 3: level 1 / level 2 Retail pharmacy tier 24: level 1 / level 2 Retail pharmacy tier 14: level 1 / level 2 Level 1 / Level 2 Pharmacy Tier 1, 2: No deductible Tier 3, 4: Medical deductible applies Pharmacy deductible3 (for tiers with deductible, cost share applies after deductible) Hospital: outpatient surgery hospital facility (includes maternity, mental health / substance use) Hospital: inpatient admission (includes maternity, mental health / substance use)ĭeductible, then $500 copay and 50% coinsurance MRI, CT scan)ĭeductible, then $300 copay and 50% coinsuranceĭeductible, then $50 copay and 10% coinsuranceĮmergency room care (Copay waived if admitted into the hospital from the emergency room.)ĭeductible, then $500 copay and 10% coinsurance Outpatient advanced diagnostic tests (Ex. Office visit: specialist (Other office services may be subject to deductible and plan coinsurance) Office visit: primary care physician (PCP)2,3 (Other office services may be subject to deductible and plan coinsurance) Out-of-Pocket Maximum An out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (percentage may vary for some covered services) Individual Coinsurance What % you pay after your deductible has been met and before your out of pocket max Individual Deductible a specified amount of money that the insured must pay before an insurance company will pay a claim. Anthem Blue Cross and Blue Shield Gold DirectAccess, a Multi-State Plan (1GFE)
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