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Anthem Blue Cross : Medical Plan Description Forms for Large Groups (51 or more Employees)

Medical Plan Description Forms for Large Groups (51 or more Employees)

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Please note our extensive list of Anthem Blue Cross Large Group plans, including those marketed by the agent community. These plans can be used for Members who reside in California and outside of California.  
Anthem Blue Cross HMO Plans
Anthem Blue Cross PPO Plans
Lumenos Consumer Driven Health PPO Plans
 
Note: Summaries for groups with effective dates of 4/1/14 and later can be accessed on this page. For Spanish versions, click here. For groups renewing through 12/31/2014, please use the plans at the link below.  

Anthem Blue Cross HMO Plans

Traditional Network HMO Plans 
Premier HMO Plans  
100% Facility Coverage  
Premier HMO 10 100% (Rx Copay - $10/$25/$45/20%)
Premier HMO 15 100% (Rx Copay - $10/$25/$45/20%)
Premier HMO 20/100% (Rx Copay - $10/$25/$45/20%)
Premier HMO 30/100% (Rx Copay - $10/$25/$45/20%)
 
Per Admit Copay on Facility  
Premier HMO 15 (Rx Copay - $10/$25/$45/20%)
Premier HMO 20 (Rx Copay - $10/$25/$45/20%)
Premier HMO 25 (Rx Copay - $10/$25/$45/20%)
Premier HMO 30 (Rx Copay - $10/$25/$45/20%)
 
Classic HMO Plans  
Classic HMO 15/30/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
Classic HMO 20/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
Classic HMO 20/40/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
Classic HMO 30/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
Classic HMO 30/40/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
Classic HMO 35/45/750 admit/375 OP (Rx Copay - $10/$30/$50)
 
Value HMO Plans  
Value HMO 20/40/250/3 day (Rx Copay - $15/$30/$50)
Value HMO 20/40/250/3 day/20% (Rx Copay - $15/$30/$50)
Value HMO 30/40/500/3 day (Rx Copay - $15/$30/$50)
Value HMO 30/40/500/3 day/20% (Rx Copay - $15/$30/$50)
Value HMO 30/40/750/3 day (Rx Copay - $15/$30/$50/$150)
Value HMO 30/45/1000/3 day (Rx Copay - $15/$30/$50/$250)
 
Value Coinsurance HMO  
Value HMO 20/30/20% (Rx Copay - $15/$30/$50)
Value HMO 25/40/20% (Rx Copay - $15/$30/$50)
Value HMO 30/40/30% (Rx Copay - $15/$30/$50/$150)
Value HMO 45/50/50% (Rx Copay - $15/$30/$50/$250)
 
Value Deductible HMO  
Value Deductible HMO $1,000 25/40/0% (Rx Copay - $15/$30/$50)
Value Deductible HMO $1,000 25/40/10% (Rx Copay - $15/$30/$50)
Value Deductible HMO $1,000/30/400%/500 OP (Rx Copay - $15/$30/$50)
Value Deductible HMO $2,000 30/45/20% (Rx Copay - $15/$30/$50/$250)
 
Advantage HMO Plans  
Advantage HMO 15 or 30 250 admit (Rx Copay - $15/$30/$50)
Advantage HMO 20 or 40 500 admit (Rx Copay - $15/$30/$50)
 
Anthem Elements Choice  
Anthem Elements Choice HMO 1500 (Rx Copay- $15/$35/30%/$500)
Anthem Elements Choice HMO 5900 (Rx Copay- $15/$50/30%/$500)
 
Select Network HMO Plans 
Select Premier HMO Plans 
100% Facility Coverage  
SH-Premier HMO 10 100% (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 15 100% (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 20/100% (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 30/100% (Rx Copay - $10/$25/$45/20%)
 
Per Admit Copay on Facility  
SH-Premier HMO 15 (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 20 (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 25 (Rx Copay - $10/$25/$45/20%)
SH-Premier HMO 30 (Rx Copay - $10/$25/$45/20%)
 
Select Classic HMO Plans  
SH-Classic HMO 15/30/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
SH-Classic HMO 20/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
SH-Classic HMO 20/40/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
SH-Classic HMO 30/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
SH-Classic HMO 30/40/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
SH-Classic HMO 35/45/750 admit/375 OP (Rx Copay - $10/$30/$50/30%)
 
Value Copay HMO  
SH-Value HMO 20/40/250/3 day (Rx Copay - $15/$30/$50)
SH-Value HMO 20/40/250/3 day/20% (Rx Copay - $15/$30/$50)
SH-Value HMO 30/40/500/3 day (Rx Copay - $15/$30/$50)
SH-Value HMO 30/40/500/3 day/20% (Rx Copay - $15/$30/$50)
SH-Value HMO 30/40/750/3 day (Rx Copay - $15/$30/$50/$150)
SH-Value HMO 30/45/1000/3 day (Rx Copay - $15/$30/$50/$250)
 
Value Coinsurance HMO  
SH-Value HMO 20/30/20% (Rx Copay - $15/$30/$50)
SH-Value HMO 25/40/20% (Rx Copay - $15/$30/$50)
SH-Value HMO 30/40/30% (Rx Copay - $15/$30/$50/$150)
SH-Value HMO 45/50/50% (Rx Copay - $15/$30/$50/$250)
 
Value Deductible HMO  
SH-Value Deductible HMO $1,000 25/40/0% (Rx Copay - $15/$30/$50)
SH-Value Deductible HMO $1,000 25/40/10% (Rx Copay - $15/$30/$50)
SH-Value Deductible HMO $1,000/30/400%/500 OP (Rx Copay - $15/$30/$50)
SH-Value Deductible HMO $2,000 30/45/20% (Rx Copay - $15/$30/$50/$250)
 
Anthem Elements Choice  
SH-Anthem Elements Choice HMO 1500 (Rx Copay- $15/$35/30%/$500)
SH-Anthem Elements Choice HMO 5900 (Rx Copay- $15/$50/30%/$500)
 
Plus Network HMO Plans 
Select Plus Premier HMO Plans  
100% Facility Coverage  
SPH-Premier HMO 10 100% (Rx Copay - $10/$25/$45/20%)
SPH-Premier HMO 15 100% (Rx Copay - $10/$25/$45/20%)
SPH -Premier HMO 20/100% (Rx Copay - $10/$25/$45/20%)
SPH-Premier HMO 30/100% (Rx Copay - $10/$25/$45/20%)
 
Per Admit Copay on Facility  
SPH-Premier HMO 15 (Rx Copay - $10/$25/$45/20%)
SPH-Premier HMO 20 (Rx Copay - $10/$25/$45/20%)
SPH-Premier HMO 25 (Rx Copay - $10/$25/$45/20%)
SPH-Premier HMO 30 (Rx Copay - $10/$25/$45/20%)
 
Select Plus Classic HMO Plans  
SPH-Classic HMO 15/30/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
SPH-Classic HMO 20 250 admit 125 OP (Rx Copay - $10/$30/$50/30%)
SPH-Classic HMO 20/40/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
SPH-Classic HMO 30/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
SPH-Classic HMO 30/40/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
SPH-Classic HMO 35/45/750 admit/375 OP (Rx Copay - $10/$30/$50/30%)
 
Select Plus Value Copay HMO  
SPH-Value HMO 20/40/250/3 day (Rx Copay - $15/$30/$50)
SPH-Value HMO 20/40/250/3 day/20% (Rx Copay - $15/$30/$50)
SPH-Value HMO 30/40/500/3 day (Rx Copay - $15/$30/$50)
SPH-Value HMO 30 40 500 3 day 20% (Rx Copay - $15/$30/$50)
SPH-Value HMO 30/40/750/3 day (Rx Copay - $15/$30/$50/$150)
SPH-Value HMO 30/45/1000/3 day (Rx Copay - $15/$30/$50/$250)
 
Value Coinsurance HMO  
SPH-Value HMO 20/30/20% (Rx Copay - $15/$30/50)
SPH-Value HMO 25/40/20% (Rx Copay - $15/$30/$50)
SPH-Value HMO 30/40/30% (Rx Copay - $15/$30/$50/$150)
SPH-Value HMO 45/50/50% (Rx Copay - $15/$30/$50/$250)
 
Value Deductible HMO  
SPH-Value Deductible HMO $1,000 25/40/0% (Rx Copay - $15/$30/$50)
SPH-Value Deductible HMO $1,000 25/40/10% (Rx Copay - $15/$30/$50)
SPH-Value Deductible HMO $1,000/30/400%/500 OP (Rx Copay - $15/$30/$50)
SPH-Value Deductible HMO $2,000 30/45/20% (Rx Copay - $15/$30/$50/$250)
 
Advantage Plus HMO Plans  
SPH-Advantage Plus HMO 15 or 30 250 admit (Rx Copay - $15/$30/$50)
SPH-Advantage Plus HMO 20 or 40 500 admit (Rx Copay - $15/$30/$50)
 
Anthem Elements Choice  
SPH-Anthem Elements Choice HMO 1500 (Rx Copay- $15/$35/30%/$500)
SPH-Anthem Elements Choice HMO 5900 (Rx Copay- $15/$50/30%/$500)
 
Priority Select Network HMO Plans  
Premier HMO Plans  
100% Facility Coverage  
PSH-Premier HMO 10 100% (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 15 100% (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 20/100% (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 30/100% (Rx Copay - $10/$25/$45/20%)
Per Admit Copay on Facility  
PSH-Premier HMO 15 (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 20 (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 25 (Rx Copay - $10/$25/$45/20%)
PSH-Premier HMO 30 (Rx Copay - $10/$25/$45/20%)
 
Classic HMO Plans  
PSH-Classic HMO 15/30/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
PSH-Classic HMO 20/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
PSH-Classic HMO 20/40/250 admit/125 OP (Rx Copay - $10/$30/$50/30%)
PSH-Classic HMO 30/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
PSH-Classic HMO 30/40/500 admit/250 OP (Rx Copay - $10/$30/$50/30%)
PSH-Classic HMO 35/45/750 admit/375 OP (Rx Copay - $10/$30/$50/30%)
 
Value HMO Plans  
PSH-Value HMO 20/40/250/3 day (Rx Copay - $15/$30/$50)
PSH-Value HMO 20/40/250/3 day/20% (Rx Copay - $15/$30/$50)
PSH-Value HMO 30/40/500/3 day (Rx Copay - $15/$30/$50)
PSH-Value HMO 30 40 500 3 day/20% (Rx Copay - $15/$30/$50)
PSH-Value HMO 30/40/750/3 day (Rx Copay - $15/$30/$50/$150)
PSH-Value HMO 30/45/1000/3 day (Rx Copay - $15/$30/$50/$250)
 
Value Coinsurance HMO  
PSH-Value HMO 20/30/20% (Rx Copay - $15/$30/$50)
PSH-Value HMO 25/40/20% (Rx Copay - $15/$30/$50)
PSH-Value HMO 30/40/30% (Rx Copay - $15/$30/$50/$150)
PSH-Value HMO 45/50/50% (Rx Copay - $15/$30/$50/$250)
 
Value Deductible HMO  
PSH-Value Deductible HMO $1,000 25/40/0% (Rx Copay - $15/$30/$50)
PSH-Value Deductible HMO $1,000 25/40/10% (Rx Copay - $15/$30/$50)
PSH-Value Deductible HMO $1,000/30/400%/500 OP (Rx Copay - $15/$30/$50)
PSH-Value Deductible HMO $2,000 30/45/20% (Rx Copay - $15/$30/$50/$250)
 
Anthem Elements Choice  
PSH-Anthem Elements Choice HMO 1500 (Rx Copay- $15/$35/30%/$500)
PSH-Anthem Elements Choice HMO 5900 (Rx Copay- $15/$50/30%/$500)
 

Anthem Blue Cross PPO Plans

Premier Plus PPO Plans 
Premier Plus 0/10/10 (Rx Copay - $5/$10/$3000 infertility)
Premier Plus 250/20/10 (Rx Copay - $10/$20/$3000 infertility)
 
Premier PPO Plans  
Premier PPO 150/10/10 (Rx Copay - $10/$25/$45)
Premier PPO 250/10/10 (Rx Copay - $10/$25/$45)
Premier PPO 250/15/10 (Rx Copay - $10/$25/$45)
Premier PPO 250/15/20 (Rx Copay - $10/$25/$45)
Premier PPO 250/20/20 (Rx Copay - $10/$25/$45)
Premier PPO 500/20/20 (Rx Copay - $10/$25/$45)
 
Classic PPO Plans 
Classic PPO 250/20/10 (Rx Copay - $10/$30/$50/30%)
Classic PPO 250/20/20 (Rx Copay - $10/$30/$50/30%)
Classic PPO 500/20/10 (Rx Copay - $10/$30/$50/30%)
Classic PPO 500/20/20 (Rx Copay - $10/$30/$50/30%)
Classic PPO 500/30/20 (Rx Copay - $10/$30/$50/30%)
Classic PPO 500/35/20 (Rx Copay - $15/$30/$50)
Classic PPO 750/30/20 (Rx Copay - $15/$30/$50)
Classic PPO 1000/30/20 (Rx Copay - $15/$30/$50)
 
One Plan PPO Plans  
OnePlan PPO 10 (Rx Copay - $10/$30/$50/30%)
OnePlan PPO 20 (Rx Copay - $10/$30/$50/30%)
OnePlan PPO 30 (Rx Copay - $10/$30/$50/30%)
 
Solution PPO Plans  
Solution PPO 1500/15/20 (Rx Copay $10/$25/$50/$250)
Solution PPO 2000/20/20 (Rx Copay $10/$25/$50/$250)
Solution PPO 2500/25/20 (Rx Copay - $10/$25/$50/$250)
Solution PPO 3500/35/35 (Rx Copay - $10/$25/$50/$250)
Solution PPO 5000/40/40 (Rx Copay - $10/$25/$50/$250)
 
Advantage PPO Plans 
Premier Advantage PPO 250/15/20/30 (Rx Copay - $10/$25/$45)
Premier Advantage PPO 250/20/20/40 (Rx Copay - $10/$25/$45)
Premier Advantage PPO 250/30/20/40 (Rx Copay - $10/$25/$45)
Classic Advantage PPO 500/30/20/30 (Rx Copay - $10/$30/$50/30%)
Classic Advantage PPO 500/30/20/40 (Rx Copay - $10/$30/$50/30%)
 
Exclusive Premier 
Exclusive Premier 15/100 admit/50 OP (Rx copay- $10/$30/$50/30%)
 
Exclusive Classic  
Exclusive Classic 20/250 admit/125 OP (Rx copay- $10/$30/$50/30%)
Exclusive Classic 30/500 admit/250 OP (Rx copay- $10/$30/$50/30%)
 
Exclusive Value 3  
Exclusive Value 30/30 (Rx copay- $10/$30/$50/30%)
 
ACO Flex PPO Plans  
Premier ACO Flex 250/15/30 (Rx Copay - $10/$25/$45)
Premier ACO Flex 500/20/35 (Rx Copay - $10/$25/$45)
Classic ACO Flex 750/30/45 (Rx copay- $10/$30/$50)
Classic ACO Flex 1500/35/50 (Rx copay- $10/$30/$50)
 
Anthem Elements Choice  
Anthem Elements Choice PPO 5900 ($15/$35/30%/$500)
SPP-Anthem Elements Choice PPO 5900 ($15/$35/30%/$500)
Anthem Elements Choice PPO 6000 ($15/$50/30%/$400)
SPP-Anthem Elements Choice PPO 6000 ($15/$50/30%/$400)
 

Lumenos Consumer Driven Health PPO Plans

The following plans are effective as of 6/2014  
Lumenos Health Savings Account (HSA) PPO Plans  
Lumenos HSA 1250/10/30 ($10/$30/$50) (LHSA287)
Lumenos HSA 2500/0/30 (LHSA633)
Lumenos HSA 1500/3000/10/30 ($10/$30/$50) (LHSA497)
Lumenos HSA 2500/3500/0/30 ($10/$30/$50) (LHSA498)
Lumenos HSA 2500/3500/20/40 ($10/$30/$50) (LHSA499)
Lumenos HSA 2500/5000 20/50 (LHSA500)
Lumenos HSA 3000/20/40 ($10/$30/$50) (LHSA291)
Lumenos HSA 3000/6000/20/40 ($10/$30/$50) (LHSA501)
Lumenos HSA 1500/20/40 ($10 $30 $50) (LHSA708)
 
Lumenos Health Savings Account (HSA) Office Visit Copay  
Lumenos HSA (copay) 2500/5000/20/30 ($10 $30 $50) (LHSA709)
 
Lumenos Health Savings Account (HSA) Embedded Deductible PPO Plans  
Lumenos HSA 2500/20/40 Embedded Ded ($10/$30/$50) (LHSA292)
Lumenos HSA 2500/3500/20/40 Embedded Ded ($10/$30/$50) (LHSA502)
Lumenos HSA 3000/0/30 Embedded Ded ($10/$30/$50) (LHSA235)
 
Lumenos Health Savings Account (HSA) Office Visit Copay Embedded  
Lumenos HSA (copay) Embedded 3000/0/30 ($10 $30 $50) (LHSA710)
 
Anthem Elements Choice PPO HSA  
Anthem Elements Choice PPO HSA 4500
Anthem Elements Choice HSA 6350
SPP-Anthem Elements Choice PPO HSA 4500
SPP-Anthem Elements Choice HSA 6350
 
Lumenos Health Reimbursement Account (HRA) PPO Plans 
Lumenos HRA 1500/10/30 ($10/$30/$50) (LHRA408)
Lumenos HRA 1500/10/30 1X Rollover ($10/$30/$50) (LHRA390)
Lumenos HRA 1500/10/30 2X Rollover ($10/$30/$50) (LHRA389)
Lumenos HRA 1500/2500/10/30 ($10/$30/$50) (LHRA872)
Lumenos HRA 2000/20/40 ($10/$30/$50) (LHRA409)
Lumenos HRA 2000/20/40 1X Rollover ($10/$30/$50) (LHRA391)
Lumenos HRA 2000/20/40 2X Rollover ($10/$30/$50) (LHRA392)
Lumenos HRA 2000/3000/20/40 ($10/$30/$50) (LHRA873)
Lumenos HRA 3000/0/30 ($10/$30/$50) (LHRA410)
Lumenos HRA 3000/0/30 1X Rollover ($10/$30/$50) (LHRA421)
Lumenos HRA 3000/0/30 2X Rollover ($10/$30/$50) (LHRA422)
 
Lumenos Health Reimbursement Account (HRA) First Dollar Copay PPO Plans  
Lumenos HRA First Dollar Copay 1500/10/30 ($10 $30 $50) (LHRA961)
Lumenos HRA First Dollar Copay 2000/20/40 ($10 $30 $50) (LHRA962)
Lumenos HRA First Dollar Copay 3000/0/30 ($10 $30 $50) (LHRA963)
 
Lumenos HIA Plus PPO Plans 
Lumenos HIA Plus 1500/10/30 ($10/$30/$50) (LHIA Plus 276)
Lumenos HIA Plus 1500/2500/10/30 ($10/$30/$50) (LHIA Plus 316)
Lumenos HIA Plus 2000/20/40 ($10/$30/$50) (LHIA Plus 277)
Lumenos HIA Plus 2000/3000/20/40 ($10/$30/$50) (LHIA Plus 317)
Lumenos HIA Plus 3000/0/30 ($10/$30/$50) (LHIA Plus 278)
 
Lumenos HIA Plus First Dollar Copay PPO Plans  
Lumenos HIA Plus First Dollar Copay 1500/10/30 ($10 $30 $50) (LHIA Plus 324)
Lumenos HIA Plus First Dollar Copay 2000/20/40 ($10 $30 $50) (LHIA Plus 325)
Lumenos HIA Plus First Dollar Copay 3000/0/30 ($10 $30 $50) (LHIA Plus 326)
 

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.