What you pay for care depends on where you get care.
| Tier 1 UC Medical Center providers |
Tier 2 From an Anthem PPO Network Provider |
Tier 3 From an Out-of-Network Provider1 |
|
|---|---|---|---|
| Benefit-Year Deductible2 |
$0 |
$100 Individual $200 Family |
$200 Individual $500 Family |
|
Benefit-Year Out-of-Pocket Maximum |
$1,000 Individual $2,000 Family |
$1,000 Individual $2,000 Family |
$2,000 Individual $4,000 Family |
|
$0 |
$0 |
$0 |
|
|
Doctor, Specialist and Therapist Office Visits |
$15 copayment |
$15 copayment |
30% |
| Virtual Care (LiveHealth Online) | Not applicable | $15 per visit | Not applicable |
| Virtual Care (LiveHealth Online Psychology) | Not applicable | $15 per visit | Not applicable |
|
Urgent Care Visits |
$15 copayment |
$15 copayment |
30% |
|
Emergency Room Visits |
$0 |
$100 copayment |
$100 copayment |
|
Inpatient Hospitalization4 |
$250 copayment |
10% |
30% |
1. In addition to any deductible and coinsurance, you are responsible for any billed charge that exceeds Anthem’s maximum allowed amount for services provided by an out-of-network provider. For outpatient non-emergency services or surgery at an out-of-network facility, the maximum plan payment amount is $350 per day. For outpatient surgery at an out-of-network ambulatory surgical center, the maximum plan payment amount is $350 per day. For inpatient non-emergency services at an out-of-network facility, the maximum plan payment amount is $600 per day.
2. In-network and out-of-network benefit-year deductibles are separate—what you pay toward one doesn’t count toward the other. UC Medical center deductibles apply to the Anthem PPO in-network deductible. The deductible and out-of-pocket maximum reset every year on July 1.
3. Not all services provided during a preventive care visit are considered preventive health benefits. For more information about what services are covered, go to anthem.com/ca.
4. An additional copay of $250 applies if you do not receive preauthorization for non-network providers.
Emergency Room Billing
Most emergency rooms are in-network, meaning they have a contract with Anthem. In rare 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 (833) 674-9256. They can help you understand your responsibility and advocate on your behalf for a lower bill.