Benefit Information (ABF) Zoe Center for Pediatric and Adolescent Health LLC
Effective June 1, 2025 through May 31, 2026
1500 Ded Plan Embedded Essential
3000 Ded Plan Embedded Essential
Blue Open Access POS
Blue Open Access POS
Custom
Custom
Deductible (individual/family) Coinsurance Out-of-pocket maximum (individual/family) Office visit (PCP/ specialist) copay Inpatient / Outpatient Copay (Surgery) Emergency Room / Urgent Care Copay Prescription Drugs – Retail
$1,500 / $4,500
$3,000 / $9,000
10%
20%
$4,500 / $9,000
$7,900 / $15,800
$0/$60
$0/$60
Ded & Coins/Ded & Coins
Ded & Coins/Ded & Coins
$500 + Coins/$75
$500 + Coins/$75
$15/$35/$60/25% to $350
$15/$35/$60/25% to $350
Prescription Drugs – Mail Order OON Deductible (individual/family) OON Coinsurance OON OOP Max (individual/family)
$3,000 / $6,000 $38/$88/$150
$6,000 / $12,000 $38/$88/$150
30%
50%
$9,000 / $18,000
$15,800 / $31,600
Benefit categories reflect In-network benefits unless noted as Out-Of-Network (OON)
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. - 0546032-03
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