Anthem HMO & EPO Options - Plan Details
Elements Choice HMO 1500
Plan Highlights In-network Coverage Only
EPO 3000
Classic HMO
Available Where? Network Name HSA Compatible?
California Only
Non-California
California Only
California Care HMO
EPO
California Care HMO
No
No
No
Annual Plan Deductible
$1,500 per covered member
$3,000 / $6,000
$0 / $0
Individual / Family Annual Out-of-Pocket Maximum
$6,400 / $12,800
$7,350 / $14,700
$2,500 / $5,000
Individual / Family Professional Services PCP Office Visits
$25 copay per visit $50 copay per visit
$25 copay per visit $50 copay per visit
$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
No charge No charge
No charge No charge
$100 copay per visit $25 copay per visit
20% coinsurance after ded. 20% coinsurance after ded.
$100 copay per visit $40 copay per visit
Hospital Services
Inpatient Services
30% coinsurance after ded. 20% coinsurance after ded. 30% coinsurance after ded. 20% coinsurance after ded. $100 copay per trip 20% coinsurance after ded.
$750 copay per admit $375 copay per visit $100 copay per trip
Outpatient Surgery - ASC*
Ambulance
$250 copay after deductible then 30% $25 copay per visit
$150 copay after deductible then 20% $25 copay per visit
Emergency Room
$125 copay per visit
Urgent Care
$40 copay per visit
Prescription Drugs Rx Deductible (Ind./Family)
None
None
None
Generic (Tier 1a / 1b)
$5 /$15 copay
$5 / $5 copay
$5 / $15 copay
Preferred brand name - (Tier 2) Non-preferred brand name - (Tier 3) Mental Health / Substance Abuse Inpatient Services
$40 copay $60 copay
$20 copay $40 copay
$40 copay $60 copay
30% coinsurance after ded. 20% coinsurance after ded.
$750 copay per admit $40 copay per visit
Outpatient Services
$25 copay per visit
$25 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.
Benefits Guide 2025-26 9
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