$0 Cost Share EPO AI-AN
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Customer Reviews: Not Yet Rated
Plan Summary | |
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Plan Type | EPO |
Office Visit for Primary Doctor
|
No Charge |
Office Visit for Specialist | No Charge |
Office Visit for Other Practitioner (Nurse, Physician Assistant) | No Charge |
Annual Deductible | None |
Separate Prescription Drugs Deductible | $0 per person | $0 per group |
Coinsurance | 0% |
Retail Prescription Drugs | Generic Drugs: No Charge; Preferred Brand Drugs: No Charge; Non-Preferred Brand Drugs: No Charge; Specialty Drugs: No Charge; |
Annual Out-of-Pocket Limit | $0 |
Lifetime Maximum | Unlimited |
Health Savings Account (HSA) Eligible | No |
Out-of-Network Coverage | No |
Out-of-Country Coverage | Emergency Care Only. |
Office Visit | |
Primary Care Physician Required | Yes |
Specialist Referrals Required | No |
Preventive Care Coverage | |
Periodic Health Exam | No Charge |
Periodic OB-GYN Exam | No Charge |
Well Baby Care | No Charge |
Emergency and Urgent Care | |
Emergency Room | No Charge |
Emergency Ambulance Services | No Charge |
Urgent Care Facility | No Charge |
Prescription Drug Coverage | |
Retail Prescription Drugs | Generic Drugs: No Charge; Preferred Brand Drugs: No Charge; Non-Preferred Brand Drugs: No Charge; Specialty Drugs: No Charge; |
Separate Prescription Drugs Deductible | $0 per person | $0 per group |
Mail Order Prescription Drugs | N/A |
Mail Order Supply | N/A |
Outpatient Coverage | |
Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: No Charge Outpatient Facility Fee: No Charge |
Outpatient Lab/X-Ray | Outpatient Lab: No Charge X-rays: No Charge |
Imaging (CT and PET scans, MRIs) | No Charge |
Outpatient Mental Health | No Charge |
Outpatient Substance Abuse | No Charge |
Outpatient Rehabilitation Services (PT, OT, ST) | No Charge |
Inpatient Coverage | |
Hospitalization | Inpatient Hospital Services: No Charge Inpatient Physician and Surgical Services: No Charge |
Skilled Nursing Facility | No Charge, limited to 100 Days per Benefit Period |
Inpatient Mental Health | No Charge |
Inpatient Substance Abuse | No Charge |
Home Healthcare | No Charge, limited to 100 Visit(s) per Year |
Maternity Coverage | |
Pre & Postnatal Office Visit | No Charge |
Labor & Delivery Hospital Stay | No Charge |
Pediatric Services | |
Dental Checkup for Children | No Charge, limited to 1 Visit(s) per 6 Months |
Vision Screening for Children | No Charge, limited to 1 Visit(s) per Year |
Eye Glasses for Children | No Charge, limited to 1 Item(s) per Year |
Major Dental Coverage (Pediatric) | No Charge |
Additional Coverage | |
Chiropractic Coverage | Not Covered |
Durable Medical Equipment | No Charge |
Hospice | No Charge |
Major Dental Coverage (Adult) | Not Covered |
Vision Coverage (Adult) | Not Covered |
Out-of-Network Coverage | |
Out-of-Network Authorization Required | N/A |
Out-of-Network Annual Deductible | N/A |
Out-of-Network Annual Coinsurance | N/A |
Out-of-Network Annual Out-of-Pocket Limit | N/A |
Additional Information | |
A.M. Best Rating | A as of 12/19/2023 |
Electronic Signature for Application Available | Yes |
Details and documents about this plan | |
View Plan Brochure (Not available)
The carrier has not provided a separate document for Exclusions and Limitations. |
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
- The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.
Carrier specific notices, disclaimers and fees
- - For information on how your broker is compensated, please visit https://file.anthem.com/CA_ACA_58152.pdf
- - If you are seeking to add a dependent parent or stepparent who is eligible for or enrolled in Medicare at the time of this application, the CA Health Insurance Counseling and Advocacy Program (HICAP) can provide health insurance counseling to senior California residents free of charge. You can call HICAP at 1-800-434-0222, or contact your local HICAP county office for more details.