Following are your costs for many common treatments. For more details about these or other treatments that are not listed, go to Anthem or call Anthem Health Guide, toll-free, at (844) 437-0486, Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific).
| In-Network | Out-of-Network2 | |
|---|---|---|
| Your Monthly Contributions for Coverage | Your monthly premiums are based on your pay band | Your monthly premiums are based on your pay band |
| UC Health Savings Account Contribution (use this to pay your initial expenses before you meet the deductible) |
$500 self coverage $1,000 family coverage |
$500 self coverage $1,000 family coverage |
|
Medical/Behavioral Health Calendar-Year Deductible1 (Combined with behavioral health and pharmacy out-of-pocket expenses) The deductible is the amount you pay before the plan begins to share in the cost for covered services. |
$1,350 self coverage $2,700 family coverage |
$2,550 self coverage $5,100 family coverage |
|
Medical/Behavioral Health Out-of-Pocket Maximum3 (Combined with behavioral health and pharmacy out-of-pocket expenses) The out-of-pocket maximum is the most you’ll pay for covered health care services in a calendar year. |
$4,000 self coverage $6,400 family coverage includes deductible |
$8,000 self coverage $16,000 family coverage includes deductible |
|
Preventive Health Visits4 ACA Preventive Travel Vaccinations (hepatitis A, hepatitis B, meningitis, polio) |
$0, no deductible | 40% after deductible |
|
Physician and Specialist Office Visits Outpatient X-ray, Pathology and Lab |
20% after deductible | 40% after deductible |
| Virtual Care (LiveHealth Online) | $49 per visit until deductible is met, then $9.80 per visit | $49 per visit until deductible is met, then $9.80 per visit |
| Urgent Care | 20% after deductible | 40% after deductible |
| Outpatient Surgery at a Hospital or Ambulatory Surgical Center | 20% after deductible | 40% after deductible |
| Inpatient Non-Emergency Facility Services | 20% after deductible | 40% after deductible |
| ER Services | 20% after deductible | 20% after deductible (see “Emergency Room Billing” below) |
| Ambulance for Emergency or Authorized Transport | 20% after deductible | 20% after deductible |
| Emergency Care Outside of California or the U.S. | Access to providers for emergency and urgent care through the Blue Cross Blue Shield Global Core network | Access to providers for emergency and urgent care through the Blue Cross Blue Shield Global Core network |
1. For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. In-network expenses count toward meeting the out-of-network deductible. However, out-of-network expenses do not count toward meeting the in-network deductible.
2. You will be responsible for any billed charge that exceeds the maximum allowed amount for services provided by an out-of-network provider. Out-of-network expenses do not count toward meeting the in-network deductible or in-network out-of-pocket maximum. Outpatient surgery and inpatient non-emergency facility services from out-of-network providers are subject to a $210 maximum per visit.
3. Includes the plan deductible. For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services.
4. Not all services provided during the preventive visit are considered preventive health benefits. To learn more about which services are covered, visit Anthem.
Emergency Room Billing
Most emergency rooms are in-network, meaning they have a contract with Anthem. In some cases, you may need to get care in an out-of-network emergency room (ER). If you get a bill for an out-of-network ER visit, before paying it, call Anthem Health Guide toll-free at (844) 437-0486. They can help you understand your responsibility and advocate on your behalf for a lower bill.
A Note About Services
Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should always check ahead of time with your doctor, medical group, independent practice association, or clinic or call Anthem Health Guide to ensure that you can obtain the health care services that you need.
Privacy
Anthem Blue Cross protects the confidentiality and privacy of your personal and health information—including your name, address, telephone number, Social Security number and medical information. That’s why you are required to sign an Authorization of Release of Personal Health Information when you request health information for your spouse/same-sex domestic partner or dependents over age 18.
If you have questions about how Anthem protects your privacy and confidentiality, please Call Anthem Health Guide, toll-free, at (844) 437-0486, or view the privacy policy.