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Below form is for California only

Anthem Blue Cross $3,500 DEDUCTIBLE PPO

(877)566-5454 Toll Free

Brochure Apply Online Download Application
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$3,500 Per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.)
Lifetime Maximum	$5,000,000 per member
Annual Out-of-Pocket Max. (includes deductible)	This is satisfied once the annual deductible is met	$10,000 per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.)
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	30% of customary and reasonable fees plus excess charges (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) Amounts shown are for each 30-day retail or in-network mail order supply	$10 copay generic; $30 copay brand-name after annual $500 brand-name prescription drug deductible; 30% of negotiated fee for self-administered injectables, except insulin	50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benefits; subject to the annual $500 brand-name prescription drug deductible
Other Anthem Blue Cross PPO Share Plan Links PPO Share $500 PPO Share $1000 PPO Share $1500 PPO Share $2500

  Download Your $3,500 Deductible PPO Brochure  
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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