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Below form is for California only

Anthem Blue Cross PPO $3500 (HSA-Compatible)

(877)566-5454 Toll Free

Brochure Apply Online Download Application
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible (Combined for medical benefits & prescription drugs)	Single member :$3,500 Families: $7,000 aggregate
Lifetime Maximum	$5,000,000 per member
Annual Out-of-Pocket Max. (Combined for medical benefits & prescription drugs)	Single member: $5,000 Families: $10,000 aggregate
Doctors' Office Visits	$0 after deductible	50% of negotiated fee plus all excess charges (after deductible)
Professional Services (X-ray, lab, anesthesia, surgeon, etc.)	$0 after deductible	50% of negotiated fee plus all excess charges (after deductible)
Hospital Inpatient (Overnight Hospital Stays)	$0 after deductible	All Charges except $650 per day (after deductible)
Hospital Inpatient (If You Don't Stay Overnight)	$0 after deductible	All Charges except $380 per day (after deductible)
Emergency Room Services	$0 after deductible	All charges in excess of customary and reasonable fees (after deductible)
Maternity	Not Covered
Preventive Care	Routine mmammogram, Pap and PSA tests: $0 after deductible Well Baby & Well Child (through age 6): $0 after deductible HealthyCheckSM Centers: $25/$75 copay for basic/premium screening (deductible waived)	Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges (after deductible) Well Baby & Well Child (through age 6): 50% of negotiated fee plus all excess charges (after deductible)
Ambulance	$0 after deductible	50% of negotiated fee plus all excess charges (after deductible)
Physical & Occupational Therapy; Chiropractic Services	$0 after deductible	All charges except $25 per visit (after deductible)
Accupunture/Accupressure	All charges except $25 per visit, up to 24 visits per year (after deductible)
Prescription Drugs (Anthem Blue Cross Formulary Drugs)	$10 copay generic; $30 copay brand-name (after annual deductible); 30% of negotiated fee for self-administered injectables, except insulin (after annual deductible)	50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benefits (after annual deductible)
Other Anthem Blue Cross PPO Share Plan Links PPO Share $500 PPO Share $1000 PPO Share $1500 PPO Share $2500

  PPO $3,500 (HSA-Compatible) Brochure  
Health Savings Accounts (HSAs) Information

Apply for Anthem Blue Cross Health Online

Or you can fill in this form to have your Anthem Blue Cross Health Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 1-877-Look4Life (1-877-566-5454).

Customer Information
Name
E-mail
Street address
City
County
State
Zip Code
Home Phone
Work Phone
FAX
My Age
Smoker?	Yes No
Spouse's Age
Spouse Smoker?	Yes No
People Covered	-- Please Select -- Me Only Me and 1 Child Me and Children Me and Spouse Family

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