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Below form is for California only

Anthem Blue Cross BASIC PPO $1,000

(877)566-5454 Toll Free

Brochure Apply Online Download Application
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$1,000 Per member, inpatient or surgical procedures only (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)	$3,500 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family)
Doctors' Office Visits	No office visit benefit until out-of-pocket maximum is met, then plan pays 100% of negotiated fee	No office visit benefit until out-of-pocket maximum is met, then you pay 50% of negotiated fee plus all excess charges
Professional Services (X-ray, lab, anesthesia, surgeon, etc.)	20% of negotiated fee for inpatient or surgical procedures only. No office visit benefits until out-of-pocket maximum is met, then plan pays 100% of negotiated fee	50% of negotiated fee, plus excess charges for covered inpatient or surgical procedures only
Hospital Inpatient (Overnight Hospital Stays)	20% of negotiated fee	All Charges except $650 per day
Hospital Inpatient (If You Don't Stay Overnight)	20% of negotiated fee	All Charges except $380 per day
Emergency Room Services	20% of negotiated fee	20% of customary and reasonable fees plus excess charges
Maternity	Not Covered
Preventive Care	Routine mammogram, Pap and PSA tests: 20% of negotiated fee (deductible waived) HealthyCheck Centers: $25/$75 copay for basic/premium screening (deductible waived)	Routine mammogram, Pap and PSA tests: 50% of negotiated fee plus all excess charges (deductible waived)
Ambulance	20% of negotiated fee	50% of negotiated fee plus all charges in excess of negotiated fee and in excess of the plans $750 maximum payment per ground trip
Physical & Occupational Therapy; Chiropractic Services	Not covered unless during inpatient admission
Accupunture/Accupressure	Not Covered
Prescription Drugs	Not Covered
Other Anthem Blue Cross Basic/Saver PPO Plan Links PPO Saver Basic PPO $1000 Basic PPO $2500

  Download Your Basic / Saver 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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