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Below form is for California only

Anthem Blue Cross RIGHTPLAN PPO 40

(877)566-5454 Toll Free

Brochure Apply Online Download Application
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$0
Lifetime Maximum	$5,000,000
Annual Out-of-Pocket Max.	$7,500
Doctors' Office Visits	$40 copay	50% of negotiated fee plus all excess charges
Professional Services (X-ray, lab, anesthesia, surgeon, etc.)	$40 copay	50% of negotiated fee plus all excess charges
Hospital Inpatient (Overnight Hospital Stays)	40% of negotiated fee plus $500 copay per day/4-day maximum copay per admission	All Charges except $650 per day
Hospital Inpatient (If You Don't Stay Overnight)	40% of negotiated fee plus $500 copay per surgical admission	All Charges except $380 per day
Emergency Room Services	40% of negotiated fee	40% of customary and reasonable fees plus all excess charges
Maternity	Not Covered
Preventive Care	Routine mammogram, Pap and PSA tests: $40 office visit plus 40% of negotiated fee Well Baby and Well Child (through age 6): $40 office visit plus 40% of negotiated fee HealthyCheckSM Centers: $25/$75 copay for basic/premium screening	Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges Well Baby and Well Child (through age 6): 50% of negotieated fee plus all excess charges
Ambulance	40% of negotiated fee	50% of negotiated fee plus all excess charges
Physical & Occupational Therapy; Chiropractic Services	40% of negotiated fee, up to 12 visits per year	All charges except $25 per visit, up to 12 visits per year
Accupunture/Accupressure	All Charges except $25 per visit, up to 24 visits per year
Prescription Drug Coverage Options	In-Network	Out-of-Network
RightPlan PPO 40 with No Prescription Drug Coverage (P958)	No Prescription Drug Coverage
RightPlan PPO 40 with Generic Prescription Drug Coverage (PE48) (30-day supply, retail & mail order)	$10 copay generic (Drugs on Generic Rx Formulary only)	50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benfits (Drugs on Generic Rx Formulary only)
RightPlan PPO 40 with Comprehensive Prescription Drug Coverage (PE49) (30-day supply, retail & mail order)	Anthem Blue Cross Formulary Drugs: $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 benfits; subject to the annual $500 brand-name prescription drug deductible.
Other Anthem Blue Cross PPO Share Plan Links PPO Share $1000 PPO Share $1500 PPO Share $2500 PPO Share $5000

  Download Your RightPlan 40 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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