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Below form is for California only

Anthem Blue Cross PPO SHARE $500

(877)566-5454 Toll Free

Brochure Apply Online Download Application
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$500 Per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.)
Lifetime Maximum	$5,000,000
Annual Out-of-Pocket Max. (includes deductible) Participating & non-participating provider covered services combined	$5,000 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family)
Doctors' Office Visits	30% of negotiated fee (deductible waived)	50% of negotiated fee plus excess charges (deductible waived )
Professional Services (X-ray, lab, anesthesia, surgeon, etc.)	30% of negotiated fee	50% of negotiated fee plus excess charges
Hospital Inpatient (Overnight Hospital Stays)	30% of negotiated fee	All Charges except $650 per day
Hospital Inpatient (If You Don't Stay Overnight)	30% of negotiated fee	All Charges except $380 per day
Emergency Room Services	30% of negotiated fee	30% of customary and reasonable fees plus excess charges
Maternity	30% of negotiated fee	50% of negotiated fee plus excess charges
Preventive Care	Annual physical exam(s): 30% of negotiated fee (deductible waived) OR HealthyCheckSM Centers: $25/$75 copay for basic/premium screening (deductible waived) Routine mmammogram, Pap and PSA tests: 30% of negotiated fee (deductible waived) Well Baby and Well Child (through age 6): 40% of negotiated fee (deductible waived)	Annual phyical exam(s): 50% of negotiated fee plus all exess charges (deductible waived) Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges (deductible waived) Well Baby and Well Child (through age 6): 50% of negotieated fee plus all excess charges (deductible waived)
Ambulance	30% of negotiated fee	50% of negotiated fee plus excess charges
Physical & Occupational Therapy; Chiropractic Services	30% of negotiated fee	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 (deductible waived)
Prescription Drugs (Anthem Blue Cross Formulary) Amounts shown are for each 30-day retail or in-network mail order supply	$10 copay generic; $30 copay brand-name after $250 brand-name prescription drug deductible (2-member maximum); 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 $250 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 PPO Share 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).

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People Covered	-- Please Select -- Me Only Me and 1 Child Me and Children Me and Spouse Family

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