PW_A116332
Short-term coverage that’s long on benefits
Change is a part of life. And sometimes it can affect your health insurance. Like when you’re starting a new job and your health coverage hasn’t kicked in yet. For times like these, one of our Individual Short-term PPO plans can fill the gap. These convenient plans let you:
 | Protect your health and finances with traditional health coverage on a short-term basis |
| Get coverage for as little as 30 days to a maximum of 180 days. |
| Choose from a wide range of annual deductibles from $250 to $2,000. |
| Begin coverage on any day of the month. |
It is important to note that because this policy offers coverage for a limited period of time, past or present health conditions are not covered.
If you have any questions:
| Call 1-800-777-6000, Monday – Friday, 8:00 a.m. – 6:30 p.m. (PST) to speak to a licensed agent |
| Or contact your local Anthem Blue Cross agent |
Benefits-at-a-glance for Short-term PPO plans
|
|
|
|
Plan Benefits
|
Short-Term PPO Plan
|
These amounts show your share of costs after deductibles, if any.
|
|
|
In-Network
|
Out-of-Network
|
Lifetime Maximum
(the amount the plan pays up to, per member)
|
$3,000,000
|
Deductible
(Waived for emergency treatment of accidental injuries)
|
$250, $500, $1,000, $2,000 per member, depending on plan chosen
|
Out-of-Pocket Maximum
|
$1,000 per member, participating and non-participating combined (plus deductible)
|
Professional Services
Including X-ray, lab and office visits
|
20% of negotiated fee
|
20% of negotiated fee plus any excess charges
|
Hospital Inpatient/Outpatient
|
Preferred Participating Providers
and Participating Providers:
20% of negotiated fee
|
You pay all charges except $650 per day inpatient;
$380 per day outpatient
|
Ambulatory Surgical Centers
|
20% of negotiated fee
|
You pay all charges except $380 per day
|
Emergency Services
(Deductible waived for emergency treatment of accidental injuries) $50 copay for each visit; waived for accidents or if admitted
|
20% of negotiated fee
|
Physician: 20% of customary and reasonable charges plus any excess charges
Hospital: 20% of customary and reasonable charges for the
first 48 hours plus any excess charges
|
Ambulance
Up to $1,000 maximum
|
20% of negotiated fee
|
20% of negotiated fee plus any excess charges
|
Prescription Drugs1
30-day supply; retail only;
No mail-order benefits
|
$10 generic; $30 brand-name; brand-name drug maximum of $500 per member
|
In California: you pay all charges except 50% of drug limited fee schedule;
Outside California: you pay drug limited fee schedule amount less copay as stated for participating pharmacies
|
Maternity Care
|
No benefits
|
No benefits
|
Physical Therapy, Occupational Therapy, Chiropractic Care
$1,000 per member maximum
|
20% of negotiated fee
|
20% of negotiated fee
|
1. If you request brand-name drugs, you pay the difference in cost between brand-name and generic, in addition to the brand-name copay. Generic drugs are based upon our Generic Rx Formulary.
These documents are in Adobe Portable Document Format (PDF). To view or print them, you will need Adobe Acrobat Reader, which can be downloaded free of charge from Adobe.
