Medical & Rx

Medical and RX

Anthem Blue Cross: Health Maintenance Organization (HMO) This chart gives an overview of the medical HMO options offered by Nant and its affiliates. Refer to medical benefit summaries from Anthem Blue Cross for more details. When you enroll in the HMO Plan you must choose a Primary Care Provider (PCP) from the HMO network to manage your care.

ANTHEM BLUE CROSSHMO 10/100%
In-Network
Plan FeaturesHMO
Overall DeductibleNone
Out-of-Pocket Limit$7,500 single / $15,000 family
Primary Care Visit $10 copay per visit
Specialist Care Visit$10 copay per visit
Telemedicine Visit$5 copay per visit
Preventive care/screening/immunizationNo charge
Hospital Stay (Inpatient)No charge
Outpatient SurgeryNo charge
Diagnostic Services: Lab and X-Ray No charge
Advanced Diagnostic Imaging (MRI, PET, CAT scans) $100 copay per test
Urgent Care (office setting)$10 copay per visit
Emergency Room Facility Services
(Copay waived if admitted)
$100 copay per visit
Ambulance (air and ground) $100 copay per trip
Outpatient Mental/Behavioral Health and Substance Abuse$10 copay per visit
Chiropractor Services
(60 visits per calendar year)*
$10 copay per visit
Acupuncture (60 visits per calendar year)*$10 copay per visit
Rehabilitation services
(physical/speech/occupational therapy)

(60 day limit per benefit)
$10 copay per visit
(Retail-up to a 30-day supply)
Tier 1- Typically Generic $10 copay
Tier 2- Typically Preferred/Brand$30 copay
Tier 3- Typically Non-Preferred/Specialty Drugs $50 copay
Tier 4- Typically Specialty Drugs30% (up to $200 max copay)
(Home delivery-up to a 90-day supply)
Tier 1- Typically Generic $20 copay
Tier 2- Typically Preferred/Brand$60 copay
Tier 3- Typically Non-Preferred/Specialty Drugs$100 copay
Tier 4- Typically Specialty Drugs (up to a 30 day supply)30% (up to $200 max copay)

combined with physical, occupational, and speech therapy

Anthem Premier HMO Benefit Summary

Anthem Premier HMO Summary of Benefit Coverage (SBC)

Anthem HMO Flyer

Anthem Blue Cross: Preferred Provider Organization (PPO)
This chart gives an overview of the medical PPO options at all locations offered by Nant. Refer to medical benefit summaries from Anthem Blue Cross for more details.

ANTHEM BLUE CROSS PPO
Plan FeatureIn-NetworkOut-of-Network
Overall Deductible$350 single / $1,050 family$2,000 single / $6,000 family
Out-of-Pocket Limit$7,500 single / $15,000 family$15,000 single / $30,000 family
Primary Care Visit$15 copay (deductible waived)40% after plan deductible
Specialist Care Visit$15 copay (deductible waived)40% after plan deductible
Telemedicine VisitNo ChargeNot Covered
Preventive care/screening/immunizationNo Charge (deductible waived)40% after plan deductible
Hospital Stay20% after plan deductible40% after plan deductible
Outpatient Surgery20% after plan deductible40% after plan deductible
Diagnostic Services: Lab and X-Ray20% after plan deductible40% after plan deductible
Advanced Diagnostic Imaging ( MRI, PET, CAT scans)20% after plan deductible40% after plan deductible
Emergency Room Facility Services (copay waived if admitted)$100 per admission + 20%
Ambulance (air and ground)20% after plan deductible
Outpatient Mental/Behavioral Health and Substance Abuse$15 copay (deductible waived)40% after plan deductible
Chiropractor Services (Unlimited Visits)$15 copay (deductible waived)40% after plan deductible
Acupuncture (Unlimited Visits)$15 copay (deductible waived)40% after plan deductible
Rehabilitation services
(physical/speech/occupational therapy)
$15 copay (deductible waived)40% after plan deductible
(Retail-up to a 30-day supply)
Tier 1- Typically Generic $5 Copay50% up to $250 per prescription
Tier 2- Typically Preferred / Brand 10% up to $5050% up to $250 per prescription
Tier 3- Typically Non-Preferred / Specialty Drugs 10% up to $7050% up to $250 per prescription
Tier 4- Typically Specialty Drugs30% up to $250 (30 day supply only)50% up to $250 per prescription
90 Day Mail Order2x Retail (90 Day Supply)Not Covered

Anthem Premier PPO Benefit Summary

Anthem Premier PPO Summary of Benefit Coverage (SBC)

Anthem PPO Flier

To locate an Anthem Provider, go to www.anthem.com/ca

  • Under “Providers” menu, then Provider Resources > Select “Find a Doctor”
  • Search as a Guest, then click “Continue”
  • Select “Through My Employer” under “How do you get insurance?”
  • Enter state you want to search in
  • Select the type of care you are searching for (medical)
  • Select a Plan/Network: Blue Cross HMO (CACare) – Large Group or Blue Cross PPO (Prudent Buyer) – Large Group
  • Click “Continue”
  • Enter type of provider or facility
  • Enter name of provider (optional)
  • Enter zip code, city and state
  • Select number of miles from location
  • Click “Search” to see the list of providers

Find a Doctor Online

You have the convenience and choice in pharmacy plan depending on the medical plan chosen. All plans offered have the option of retail and home delivery with nearby in-network retail locations and the convenience of home delivery pharmacy with Anthem.

National 4-Tier Drug List

Your Pharmacy Benefits

Home Delivery Pharmacy

INGENIORX Mail Order Form