Amended plans
Effective on your group’s renewal on or after January 1, 2016 Below is an overview of changes and updates made to your medical plan which will take effect with your plan’s renewal. For a complete listing of all your benefits, limitations and exclusions, please review your complete Combined Evidence of Coverage & Disclosure Form (EOC)/Certificate. Amounts listed below are member’s responsibility to pay after any applicable deductible (unless otherwise specified).
Current 2015 plan
New 2016 plan
Plan name(s)
Anthem Gold HMO 35/20%/6600, Anthem Gold Select HMO 35/20%/6600, Anthem Gold Priority Select HMO 35/20%/6600 Benefit Deductible: N/A modifications OOPM: $6,600 Office visit: $35 Specialist visit: $60 Coinsurance: 20% Urgent care: $60 Emergency room: $250 + 20% Outpatient surgery: $250 Inpatient hospital: $750 per day (up to three days) Pharmacy: $250 ded (waived for tier 1) $15/$35/$70/25% (up to $250 max per script) — retail $37.50/$87.50/$175/25% (up to $250 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
Anthem Gold HMO 50/30%/6850, Anthem Gold Select HMO 50/30%/6850, Anthem Gold Priority Select HMO 50/30%/6850 Deductible: N/A OOPM: $6,850 Office visit: $50 Specialist visit: $100 Coinsurance: 30% Urgent care: $100 Emergency room: $350 + 30% Outpatient surgery: $500 Inpatient hospital: $750 per day (up to four days) Pharmacy: $250 ded (waived for tier 1) $15/$50/$90/25% (up to $250 max per script) — retail $37.50/$150/$270/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 Healthy Support: None
Plan name(s)
Anthem Gold Select HMO 500/20%/5000, Anthem Gold Priority Select HMO 500/20%/5000 Deductible: $500 OOPM: $5,000 Office visit: $30 Specialist visit: $60 Coinsurance: 20% Urgent care: $100 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $250 ded (waived for tier 1) $15/$40/$80/25% (up to $250 max per script) — retail $37.50/$120/$240/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 Healthy Support: None
Anthem Gold Select HMO 500/20%/4500 Plus, Anthem Gold Priority Select HMO 500/20%/4500 Plus Benefit Deductible: $500 modifications OOPM: $4,500 Office visit: $30 Specialist visit: $60 Coinsurance: 20% Urgent care: $80 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $15/$35/$70/30% (up to $500 max per script) — retail $37.50/$87.50/$175/30% (up to $500 max per script) — home delivery Rx Formulary: Adult vision exam: Healthy Support:
48663CAMENABC Rev. 09/15
Select Drug List Not covered CCP Package A
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. 1 of 7
Current 2015 plan
New 2016 plan
Plan name(s)
Anthem Silver HMO 1500/30%/6550, Anthem Silver Select HMO 1500/30%/6550, Anthem Silver Select HMO 1500/30%/6550 Benefit Deductible: $1,500 modifications OOPM: $6,550 Office visit: $50 Specialist visit: $75 Coinsurance: 30% Urgent care: $75 Emergency room: $250 + 30% Outpatient surgery: 30% Inpatient hospital: 30% Pharmacy: $500 ded (waived for tier 1) $15/$35/$70/25% (up to $250 max per script) — retail $37.50/$87.50/$175/25% (up to $250 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
Anthem Silver HMO 2000/30%/6850, Anthem Silver Select HMO 2000/30%/6850, Anthem Silver Priority Select HMO 2000/30%/6850 Deductible: $2,000 OOPM: $6,850 Office visit: $50 Specialist visit: $75 Coinsurance: 30% Urgent care: $100 Emergency room: $350 + 30% Outpatient surgery: 30% Inpatient hospital: 30% Pharmacy: $500 ded (waived for tier 1) $15/$40/$80/25% (up to $250 max per script) — retail $37.50/$120/$240/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 Healthy Support: None
Plan name(s) Anthem Platinum Select PPO 20/10%/4000 Plus Benefit Deductible: None modifications OOPM: $4,000 Office visit: $20 Specialist office visit: $20 Coinsurance: 10% Urgent care: $40 Emergency room: $150 Outpatient surgery: 10% Inpatient hospital: 10% Pharmacy: $5/$15/$25/10% (up to $500 max per script) — retail $12.50/$37.50/$62.50/10% (up to $500 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: Not covered Healthy Support: CCP Pkg A
Anthem Platinum Select PPO 20/10%/4000 Deductible: None OOPM: $4,000 Office visit: $20 Specialist office visit: $20 Coinsurance: 10% Urgent care: $40 Emergency room: $150 Outpatient surgery: 10% Inpatient hospital: 10% Pharmacy: $5/$15/$25/10% (up to $250 max per script)— retail $12.50/$45/$75/10% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 Healthy Support: None
2 of 7
Plan name(s)
Current 2015 plan
New 2016 plan
Anthem Gold Select PPO 30/20%/6250 Plus
Anthem Gold Select PPO 35/20%/6200
Benefit Deductible: modifications OOPM: Office visit: Specialist office visit: Coinsurance: Urgent care: Emergency room: Outpatient surgery: Inpatient hospital: Pharmacy:
Rx Formulary: Adult vision exam: Healthy Support:
None $6,250 $30 $50 20% $60 $250 20% 20% $15/$50/$70/20% (up to $500 max per script) — retail $37.50/$125/$175/20% (up to $500 max per script) — home delivery Select Drug List Not covered CCP Pkg A
Plan name(s) Anthem Silver Select PPO 1500/20%/6250 Plus Benefit Deductible: $1,500 modifications OOPM: $6,250 Office visit: $45 Specialist office visit: $65 Coinsurance: 20% Urgent care: $90 Emergency room: $250 Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $500 ded (waived for tier 1) $15/$50/$70/20% (up to $250 max per script) — retail $37.50/$125/$175/20% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: Not covered Healthy Support: CCP Pkg A
Deductible: OOPM: Office visit: Specialist office visit: Coinsurance: Urgent care: Emergency room: Outpatient surgery: Inpatient hospital: Pharmacy:
Rx Formulary: Adult vision exam: Healthy Support:
None $6,200 $35 $55 20% $60 $250 20% 20% $15/$50/$70/20% (up to $250 max per script) — retail $37.50/$150/$210/20% (up to $250 max per script) — home delivery Select Drug List $20 None
Anthem Silver Select PPO 1500/20%/6500 Deductible: $1,500 OOPM: Office visit: Specialist office visit: Coinsurance: Urgent care: Emergency room: Outpatient surgery: Inpatient hospital: Pharmacy:
Rx Formulary: Adult vision exam: Healthy Support:
$6,500 $45 $70 20% $90 $250 20% 20% $250 ded (waived for tier 1) $15/$55/$75/20% (up to $250 max per script) — retail $37.50/$165/$225/20% (up to $250 max per script) — home delivery Select Drug List $20 (ded waived) None
3 of 7
Current 2015 plan
New 2016 plan
Plan name(s) Anthem Bronze Select PPO 5000/30%/6250 Plus Benefit Deductible: $5,000 modifications OOPM: $6,250 Office visit: $60 (three visits before ded) Specialist office visit: $70 (three visits before ded) Coinsurance: 20% Urgent care: $120 (three visits before ded) Emergency room: $250 Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: Deductible combined w/ medical, then 20% Rx Formulary: Adult vision exam: Healthy Support: Plan name(s)
Select Drug List Not covered CCP Pkg A
Anthem Gold PPO 500/20%/4500, Anthem Gold Select PPO 500/20%/4500 Benefit Deductible: $500 modifications OOPM: $4,500 Office visit: $30 Specialist office visit: $60 Coinsurance: 20% Urgent care: $60 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $250 ded (waived for tier 1) $15/$35/$70/25% (up to $250 max per script) — retail $37.50/$87.50/$175/25% (up to $250 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
Anthem Bronze Select PPO 6000/100%/6500 Deductible: $6,000 OOPM: $6,500 Office visit: $70 (three visits before ded) Specialist office visit: $90 (three visits before ded) Coinsurance: No coverage until OOPM is reached Urgent care: $120 (three visits before ded) Emergency room: No Coverage until OOPM is reached Outpatient surgery: No Coverage until OOPM is reached Inpatient hospital: No Coverage until OOPM is reached Pharmacy: $500 ded (all tiers) No coverage, after deductible (up to $500 max copay per script), until OOPM is reached Rx Formulary: Select Drug List Adult vision exam: $20 (ded waived) Healthy Support: None Anthem Gold PPO 500/20%/4500, Anthem Gold Select PPO 500/20%/4500 Deductible: $500 OOPM: $4,500 Office visit: $30 Specialist office visit: $60 Coinsurance: 20% Urgent care: $100 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $250 ded (waived for tier 1) $15/$40/$80/25% (up to $250 max per script) — retail $37.50/$120/$240/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 (ded waived) Healthy Support: None
4 of 7
Current 2015 plan
New 2016 plan
Plan name(s)
Anthem Gold PPO 1000/20%/4000, Anthem Gold Select PPO 1000/20%/4000 Benefit Deductible: $1,000 modifications OOPM: $4,000 Office visit: $20 Specialist office visit: $40 Coinsurance: 20% Urgent care: $40 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $250 ded (waived for tier 1) $15/$35/$70/25% (up to $250 max per script) — retail $37.50/$87.50/$175/25% (up to $250 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
Anthem Gold PPO 1000/20%/4000, Anthem Gold Select PPO 1000/20%/4000 Deductible: $1,000 OOPM: $4,000 Office visit: $20 Specialist office visit: $40 Coinsurance: 20% Urgent care: $100 Emergency room: $200 + 20% Outpatient surgery: 20% Inpatient hospital: 20% Pharmacy: $250 ded (waived for tier 1) $15/$40/$80/25% (up to $250 max per script) — retail $37.50/$120/$240/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 (ded waived) Healthy Support: None
Plan name(s)
Anthem Silver PPO 2000/35%/6850, Anthem Silver Select PPO 2000/35%/6850 Deductible: $2,000 OOPM: $6,850 Office visit: $25 Specialist office visit: $45 Coinsurance: 35% Urgent care: $100 Emergency room: $300 + 35% Outpatient surgery: 35% Inpatient hospital: 35% Pharmacy: $15/$40/$80/25% (up to $250 max per script) — retail $37.50/$120/$240/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 (ded waived) Healthy Support: None
Anthem Silver PPO 2000/35%/6600, Anthem Silver Select PPO 2000/35%/6600 Benefit Deductible: $2,000 modifications OOPM: $6,600 Office visit: $25 Specialist office visit: $45 Coinsurance: 35% Urgent care: $45 Emergency room: $300 + 35% Outpatient surgery: 35% Inpatient hospital: 35% Pharmacy: $15/$35/$70/30% (up to $500 max per script) — retail $37.50/$87.50/$175/25% (up to $500 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
5 of 7
Current 2015 plan
New 2016 plan
Plan name(s)
Anthem Bronze PPO 6000/35%/6600, Anthem Bronze Select PPO 6000/35%/6600 Benefit Deductible: $6,000 modifications OOPM: $6,600 Office visit: $70 copay (first three visits before ded), then deductible + 35% Specialist office visit: $70 copay (first three visits before ded), then deductible + 35% Coinsurance: 35% Urgent care: 35% Emergency room: 35% Outpatient surgery: 35% Inpatient hospital: 35% Pharmacy: $250 ded (waived for tier 1) $15/$50/$90/25% (up to $250 max per script) — retail $37.50/$125/$225/25% (up to $250 max per script) — home delivery Rx Formulary: National Drug List Adult vision exam: Not covered Healthy Support: None
Anthem Bronze PPO 6000/35%/6600, Anthem Bronze Select PPO 6000/35%/6600 Deductible: $6,000 OOPM: $6,600 Office visit: $70 copay (first three visits before ded), then deductible + 35% Specialist office visit: $70 copay (first three visits before ded), then deductible + 35% Coinsurance: 35% Urgent care: 35% Emergency room: 35% Outpatient surgery: 35% Inpatient hospital: 35% Pharmacy: $250 ded (waived for tier 1) $15/$50/$90/25% (up to $250 max per script) — retail $37.50/$150/$270/25% (up to $250 max per script) — home delivery Rx Formulary: Select Drug List Adult vision exam: $20 (ded waived) Healthy Support: None
Plan name(s)
Anthem Gold PPO 2000/20%/4000 w/ HRA, Anthem Gold Select PPO 2000/20%/4000 w/ HRA Employer contribution: $1,000 Deductible/OOP Embedded accumulation: Deductible: $2,000 OOPM: $4,000 Coinsurance: 20% Pharmacy: Ded combined w/medical, then 20% Rx Formulary: Select Drug List Adult vision exam: $20 copay (ded waived) CDH Incentives: N/A
Anthem Gold PPO 2000/20%/4000 w/ HRA, Anthem Gold Select PPO 2000/20%/4000 w/ HRA Benefit Employer contribution: $1,000 modifications Deductible/OOP Nonembedded accumulation: Deductible: $2,000 OOPM: $4,000 Coinsurance: 20% Pharmacy: Ded combined w/ medical, then 20% Rx Formulary: National Drug List Adult vision exam: Not covered CDH Incentives: Included
6 of 7
Current 2015 plan
New 2016 plan
Plan name(s)
Anthem Silver PPO 2000/30%/6350 w/ HSA, Anthem Silver Select PPO 2000/30%/6350 w/ HSA Benefit Employer contribution: $250 modifications Deductible/OOP Nonembedded accumulation: Deductible: $2,000 OOPM: $6,350 Coinsurance: 30% Pharmacy: Ded combined w/ medical, then 30% Rx Formulary: National Drug List Adult vision exam: Not covered CDH Incentives: Included
Anthem Silver PPO 2600/20%/5500 w/ HSA, Anthem Silver Select PPO 2600/20%/5500 w/ HSA Employer contribution: None Deductible/OOP Embedded accumulation: Deductible: $2,600 OOPM: $5,500 Coinsurance: 20% Pharmacy: Ded combined w/ medical, then 20% Rx Formulary: Select Drug List Adult vision exam: $20 copay (ded waived) CDH Incentives: N/A
Plan name(s)
Anthem Bronze PPO 5500/30%/6450 w/ HSA, Anthem Bronze Select PPO 5500/30%/6450 w/ HSA Employer contribution: $100
Anthem Bronze PPO 4500/30%/6350 w/ HSA, Anthem Bronze Select PPO 4500/30%/6350 w/ HSA Employer contribution: None
Deductible/OOP accumulation: Deductible: OOPM: Coinsurance: Pharmacy: Rx Formulary: Adult vision exam: CDH Incentives:
Deductible/OOP accumulation: Deductible: OOPM: Coinsurance: Pharmacy: Rx Formulary: Adult vision exam: CDH Incentives:
Benefit modifications
Plan name(s)
Nonembedded $5,500 $6,450 30% Ded combined w/ medical, then 30% National Drug List Not covered Included
Anthem Bronze PPO 6350/0%/6350 w/ HSA, Anthem Bronze Select PPO 6350/0%/6350 w/ HSA
Benefit Employer contribution: modifications Deductible/OOP accumulation: Deductible: OOPM: Coinsurance: Pharmacy: Rx Formulary: Adult vision exam: CDH Incentives:
$100 Nonembedded $6,350 $6,350 0% Ded combined w/ medical, then 0% National Drug List Not covered Included
Embedded $4,500 $6,350 30% Ded combined w/ medical, then 30% Select Drug List $20 copay (ded waived) N/A
Anthem Bronze PPO 6000/0%/6000 w/ HSA, Anthem Bronze Select PPO 6000/0%/6000 w/ HSA Employer contribution: None Deductible/OOP Embedded accumulation: Deductible: $6,000 OOPM: $6,000 Coinsurance: 0% Pharmacy: Ded combined w/ medical, then 0% Rx Formulary: Select Drug List Adult vision exam: $20 copay (ded waived) CDH Incentives: N/A
7 of 7
