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What You Pay for Care

What you pay for care depends on which plan you are enrolled in (PPO or HMO) and where you get care.

PPO HMO Emergency Room Billing

PPO

What you pay for care depends on where you get care.

  Tier 1
UC Medical Center and One Medical 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

Preventive Care3

$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
(waived if admitted)

$100 copayment
(waived if admitted)

Inpatient Hospitalization4

$250 copayment

10%

30%

Outpatient Surgery at a Hospital or Ambulatory Surgical Center
$350 maximum allowance for out-of-network providers
$0 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.

HMO

You can choose to receive care from a UCMC or HMO doctors, hospitals and other providers. Except for emergencies, no care is covered from non-UCMC or HMO providers.

  HMO Providers
(including UC Medical Center providers)
Benefit-Year Deductible $0

Benefit-Year Out-of-Pocket Maximum

$1,500 Individual

$2,500 Family

Preventive Care

$0

Doctor, Specialist and Therapist Office Visits

$10 copayment

Virtual Care (LiveHealth Online) $10 per visit
Virtual Care (LiveHealth Online Psychology) $10 per visit

Urgent Care Visits

$10 copayment

Emergency Room Visits

$100 copayment
(waived if admitted)

Inpatient Hospitalization*

$0

Outpatient Surgery at a Hospital or Ambulatory Surgical Center
$350 maximum allowance for out-of-network providers
$0

*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. PPO members can call (833) 674-9256, Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific). If you're an HMO member, call (833) 674-9257 Monday through Friday, 8:00 a.m. to 8:00 p.m. (Pacific). Anthem can help you understand your responsibility and advocate on your behalf for a lower bill.