Anthem PPO Options - Plan Details
Plan Highlights In-network Coverage Only
Anthem PPO HDHP HSA 4000 Anthem Classic PPO 1500
Available Where? Network Name HSA Compatible?
All States
All States
Prudent Buyer PPO
Prudent Buyer PPO
Yes
No
Annual Plan Deductible
$4,000 / $8,000
$1,500 / $4,500
Individual / Family Annual Out-of-Pocket Maximum
$7,000 / $14,000
$5,000 / $10,000
Individual / Family Professional Services PCP Office Visits
20% coinsurance after deductible 20% coinsurance after deductible
$40 copay per visit $60 copay per visit
Specialist Visits
Preventive Care Exams Diagnostic Lab and X-Ray Radiology (MRI / CT Scan) Rehabilitation Services
No charge
No charge
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
Hospital Services
Inpatient Services
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible $150 copay after deductiblel then 20%
Outpatient Surgery - ASC*
Ambulance
Emergency Room
Urgent Care
$40 copay per visit
Prescription Drugs Rx Deductible (Ind./Family)
Overall deductible must be met first $5 /$15 copay after deductible
None
Generic (Tier 1a / 1b)
$5 / $20 copay
Preferred brand name - (Tier 2) Non-preferred brand name - (Tier 3) Mental Health / Substance Abuse Inpatient Services
$40 copay after deductible $60 copay after deductible
$30 copay $50 copay
20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible
Outpatient Services
$40 copay per visit
* Ambulatory Surgical Center (ASC)
The above information is a summary only.
Please refer to your Summary of Benefit Coverage (SBC) for details of plan benefits, limitations and exclusions.
10 Benefits Guide 2025-26
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