Anthem Blue Cross and Blue Shield
Plan Description Wisconsin


   Wisconsin Health Plan Description Form

Anthem Blue Cross and Blue Shield

SUMMARY OF Anthem Health Insurance BENEFITS FOR Wisconsin

With Anthem Blue Cross Blue Shield Wisconsin you have the comfort of knowing that you’re covered in sickness, in health, in the hospital, and in emergencies, anytime, anywhere. There are no waiting periods for benefits, no deductibles to meet, and claim forms to fill out.  You’ll be recognized when you travel as a member of the Blue Cross Blue Shield Family.

These pages highlight some of the benefits of your Anthem Blue Cross Blue Shield Wisconsin plan.  The benefits described are covered when arranged by your primary care physician and coordinated by Anthem Blue Cross Blue Shield Wisconsin. Your benefit description and riders define the terms and conditions of our plan. Should any questions arise, the benefit description and riders will govern. Some of the services not covered are: custodial care; cosmetic surgery; eyeglasses; contact lenses; most dental care (other than covered pediatric preventive dental care, provided care is received from a Blue Cross and Blue Shield participating dentist); chiropractor services; hearing aids; any services covered by workers’ compensation, other party liability; or coordination of benefits.

Please note: Blue Cross and Blue Shield of Massachusetts, Inc. administers claims payments only and does not assume financial risk for claims.

Administered by: Anthem Blue Cross and Blue Shield in Wisconsin
 

Plan Name Blue Access Economy
Plan Type: PPO
Annual Out-of-Pocket Maximum: $6,500 Individual/$13,000 Family
Annual Deductible: $2,500 Individual/$7,500 Family
Office Visits: You pay $35 co-pay for first 3 visits, no deductible. (Co-pay applies to office visit charge only) 4+ visits you pay 30%; subject to annual deductible. You pay 30% for other office services; subject to annual deductible
Coinsurance (Network/Non-Network): You pay 30%/50%; subject to annual deductible
Hospital Inpatient/Outpatient: You pay 30%; subject to annual deductible
Emergency Services: You pay 30%; subject to annual deductible
Urgent Care (in Urgent Care Center): You pay 30%; subject to annual deductible
Preventive Care: You pay 30%;subject to annual deductible (Routine pap smear, annual mammogram, colorectal cancer screening and PSA screening). Other preventive services are not covered
Diagnostic Services: You pay 30%; subject to annual deductible
Ambulance Services: You pay 30%; subject to annual deductible
Mental Health: Not Covered
Financial/Tax Incentive: No  
Drug Coverage: You pay $15 on generic drugs only ($500 maximum). Brand name drugs are not covered  
Prescription Drug Co-pay: Yes

                                               
Plan Name Lumenos Health Savings Account Plan 1
Plan Type: HSA
Physician Choice: Yes
Annual Out-of-Pocket Maximum: $3,000 Individual
Annual Deductible: $3,000 Individual
Office Visits: You pay 0%; subject to calendar-year deductible
Coinsurance (Network/Non-Network): You pay 0%/30%; subject to calendar-year deductible
Hospital Inpatient/Outpatient: You pay 0%; subject to calendar-year deductible
Emergency Services: You pay 0%; subject to calendar-year deductible
Urgent Care (in Urgent Care Center): You pay 0%; subject to calendar-year deductible
Preventive Care: You pay 0%; no deductible
Mental Health: Not Covered
Drug Benefits: You pay 0%; subject to calendar-year deductible
Financial/Tax Incentive: Yes
Diagnostic Services: You pay 0%; subject to calendar-year deductible
Ambulance Services: You pay 0%; subject to calendar-year deductible
Prescription Drug Co-pay: No

 
Plan Name  Blue Access 80
Plan Type: PPO
Annual Out-of-Pocket Maximum: $5,500 Individual/$11,000 Family
Annual Deductible: $2,500 Individual/$7,500 Family
Office Visits: You pay $35 co-pay for office visit charge, no deductible. You pay 20% for other office services; subject to annual deductible
Coinsurance (Network/Non-Network): You pay 20%/40%; subject to annual deductible
Hospital Inpatient/Outpatient: You pay 20%; subject to annual deductible
Emergency Services: You pay 20%; subject to annual deductible
Urgent Care (in Urgent Care Center): You pay 20%; subject to annual deductible
Preventive Care: You pay $35 co-pay for office visit charge, no deductible. You pay 20% for other office services; subject to annual deductible
Diagnostic Services: You pay 20%; subject to annual deductible
Ambulance Services: You pay 20%; subject to annual deductible
Mental Health: Not Covered
Financial/Tax Incentive: No
Drug Coverage: You pay $15 Generic (Tier 1)/$30 Formulary Brand after $500 drug deductible (Tier 2)/$60 Non-Formulary Brand after $500 drug deductible (Tier 3)/25% self-injectibles (Tier 4)
Prescription Drug C-opay: Yes


 

Plan Name  Blue Access 100
Plan Type: PPO
Annual Out-of-Pocket Maximum: $2,500 Individual/$7,500 Family
Annual Deductible: $2,500 Individual/$7,500 Family
Office Visits: You pay $35 co-pay for office visit charge, no deductible. You pay 0% for other office services; subject to annual deductible
Coinsurance (Network/Non-Network): You pay 0%/40%; subject to annual deductible
Hospital Inpatient/Outpatient: You pay 0%; subject to annual deductible
Emergency Services: You pay 0%; subject to annual deductible
Urgent Care (in Urgent Care Center): You pay 0%; subject to annual deductible
Preventive Care: You pay $35 co-pay for office visit charge, no deductible. You pay 0% for other office services; subject to annual deductible
Diagnostic Services: You pay 0%; subject to annual deductible
Ambulance Services: You pay 0%; subject to annual deductible
Mental Health: Not Covered
Financial/Tax Incentive: No
Drug Coverage: You pay $15 Generic (Tier 1)/$30 Formulary Brand (Tier 2)/$60 Non-Formulary Brand (Tier 3)/25% self-injectibles (Tier 4)
Prescription Drug Co-pay: Yes

 

Plan Name  Blue Access Economy
Plan Type: PPO
Annual Out-of-Pocket Maximum: $5,000 Individual/$10,000 Family
Annual Deductible: $1,000 Individual/$3,000 Family
Office Visits: You pay $35 co-pay for first 3 visits, no deductible. (Co-pay applies to office visit charge only) 4+ visits you pay 30%; subject to annual deductible. You pay 30% for other office services; subject to annual deductible
Coinsurance (Network/Non-Network): You pay 30%/50%; subject to annual deductible
Hospital Inpatient/Outpatient: You pay 30%; subject to annual deductible
Emergency Services: You pay 30%; subject to annual deductible
Urgent Care (in Urgent Care Center): You pay 30%; subject to annual deductible
Preventive Care: You pay 30%;subject to annual deductible (Routine pap smear, annual mammogram, colorectal cancer screening and PSA screening). Other preventive services are not covered
Diagnostic Services: You pay 30%; subject to annual deductible
Ambulance Services: You pay 30%; subject to annual deductible
Mental Health: Not Covered
Financial/Tax Incentive: No
Drug Coverage: You pay $15 on generic drugs only ($500 maximum). Brand name drugs are not covered
Prescription Drug Co-pay: Yes