Missouri Plan Guide
for the Individual market
Effective January 1, 2014
This brochure is intended for broker
use only and should not be distributed
to consumers or employer groups.
38204MOBENABS Rev. 11/13
Anthem On-Exchange Plans
Network Name
Individual Deductible*
(Family is 2 x Individual amount)
Anthem Bronze
DirectAccess with HSA
cabp (0S9G)
Anthem Bronze
DirectAccess
cabr (0S9J)
Anthem Bronze
DirectAccess
with Child Dental
cdbr (0S9L)
Anthem Bronze
DirectAccess
caaa (0S9A)
Pathway X
Pathway X
Pathway X
Pathway X
$4,000 / $8,000
$4,300 / $8,600
$4,300 / $8,600
$5,750 / $11,500
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
20% / 50%
20% / 50%
20% / 50%
20% / 50%
$35 copay per visit
for first 2 office visits,
then 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
$40 copay per visit
for first 2 office visits,
then 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Individual OOP Limit*
(Includes deductible, copays,
coinsurance & Rx. Family is 2 x
Individual amount)
Coinsurance*
Office Visit: PCP
Deductible and
20% coinsurance
Office Visit: Specialist
Deductible and
20% coinsurance
$35 copay per visit
for first 2 office visits,
then 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Outpatient
Diagnostic Tests
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible and
20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible and
20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible and
20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible and
20% coinsurance
$500 copay then deductible
and 20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Dental
Not covered
Not covered
Vision
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limit of 26 visits per year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limit of 26 visits per year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Pediatric dental included
Adult not included
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limit of 26 visits per year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
(Examples: X-ray, EKG)
Outpatient Advanced
Diagnostic Tests
(Examples: MRI, CT scan)
Preventive Care
Urgent Care
Emergency Room Care
Hospital:
Inpatient Admission
Hospital:
Outpatient Surgery
Hospital Facility
Maternity
RX Tier 1 (Retail)
RX Tier 2 (Retail)
RX Tier 3 (Retail)
RX Tier 4 (Retail)
Mental Health
Substance Abuse
Chiropractic
Physical Therapy
* Information denoted by asterisk shows in-network / out-of-network values
$20 copay
$50 copay
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Not covered
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limit of 26 visits per year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
2
Anthem Bronze
DirectAccess
caae (0S9C)
Anthem Bronze
DirectAccess with HSA
caar (0S9E)
Anthem Silver
DirectAccess
cbjc (0S9T)
Anthem Silver
DirectAccess
cbds (0S9Y)
Anthem Silver
DirectAccess with HSA
cbbg (0SA3)
Pathway X
Pathway X
Pathway X
Pathway X
Pathway X
$6,050 / $12,100
$6,300 / $12,600
$1,750 / $3,500
$2,500 / $5,000
$3,000 / $6,000
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$3,600 / $7,200
25% / 50%
0% / 30%
20% / 50%
10% / 40%
10% / 40%
$40 copay per visit for first
3 office visits, then deductible
and 10% coinsurance.
Other office services
subject to deductible and
10% coinsurance.
Deductible and
10% coinsurance
$45 copay per visit
for first 2 office visits,
then 25% coinsurance.
Other office services
subject to deductible and
25% coinsurance.
Deductible and
25% coinsurance
Deductible and
0% coinsurance
$35 copay per visit for first
3 office visits, then deductible
and 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Deductible and
25% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
25% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 25% coinsurance
$350 copay
(waived if admitted)
then deductible and
25% coinsurance
$1,000 copay then deductible
and 25% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible and
0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible and
20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 10% coinsurance
$200 copay
(waived if admitted)
then deductible and
10% coinsurance
$500 copay then deductible
and 10% coinsurance
$50 copay then deductible
and 10% coinsurance
$200 copay
(waived if admitted)
then deductible and
10% coinsurance
$500 copay then deductible
and 10% coinsurance
25% coinsurance
0% coinsurance
20% coinsurance
10% coinsurance
10% coinsurance
$1,000 copay for inpatient
facility then deductible
and 25% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
$500 copay for inpatient
facility then deductible
and 10% coinsurance
$15 copay
$15 copay
$40 copay
$40 copay
Deductible and
25% coinsurance applies
Deductible and
25% coinsurance applies
$500 copay for inpatient
facility then deductible
and 0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
$500 copay for inpatient
facility then deductible
and 10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Not covered
Not covered
Not covered
Not covered
Not covered
Pediatric vision included
Adult not included
Deductible and
25% coinsurance
Deductible and
25% coinsurance
Deductible and
25% coinsurance
(limit of 26 visits per year)
Deductible and
25% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limit of 26 visits per year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limit of 26 visits per year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
(limit of 26 visits per year)
Deductible and
10% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
(limit of 26 visits per year)
Deductible and
10% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
$20 copay
$50 copay
Deductible and
0% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Anthem On-Exchange Plans
Anthem Silver
DirectAccess
cbaa (0S9N)
Anthem Gold
DirectAccess
ccab (0SA8)
Anthem Gold
DirectAccess
with Child Dental
cdcp (0SAA)
Anthem Catastrophic
DirectAccess
(0S98)
Pathway X
Pathway X
Pathway X
Pathway X
$3,500 / $7,000
$750 / $1,500
$750 / $1,500
$6,350 / $12,700
$4,500 / $9,000
$6,000 / $12,000
$6,000 / $12,000
$6,350 / $12,700
0% / 30%
0% / 30%
0% / 30%
0% / 30%
$45 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
$30 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
$30 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
Office Visit: Specialist
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
$40 copay per visit for first
3 office visits, then deductible
and 0% coinsurance.
Other office services
subject to deductible and
0% coinsurance.
Deductible and
0% coinsurance
Outpatient
Diagnostic Tests
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible and
0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible and
0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible and
0% coinsurance
$500 copay then deductible
and 0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
Deductible and
0% coinsurance
RX Tier 1 (Retail)
$15 copay
$15 copay
$15 copay
RX Tier 2 (Retail)
$40 copay
$40 copay
$40 copay
RX Tier 3 (Retail)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Dental
Not covered
Not covered
Vision
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limit of 26 visits per year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limit of 26 visits per year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Pediatric dental included
Adult not included
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limit of 26 visits per year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Network Name
Individual Deductible*
(Family is 2 x Individual amount)
Individual OOP Limit*
(Includes deductible, copays,
coinsurance & Rx. Family is 2 x
Individual amount)
Coinsurance*
Office Visit: PCP
(Examples: X-ray, EKG)
Outpatient Advanced
Diagnostic Tests
(Examples: MRI, CT scan)
Preventive Care
Urgent Care
Emergency Room Care
Hospital:
Inpatient Admission
Hospital:
Outpatient Surgery
Hospital Facility
Maternity
RX Tier 4 (Retail)
Mental Health
Substance Abuse
Chiropractic
Physical Therapy
* Information denoted by asterisk shows in-network / out-of-network values
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Not covered
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limit of 26 visits per year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Notes
4
Anthem Off-Exchange Plans
Network Name*
Individual Deductible*
(Family is 2 x Individual amount)
Anthem Core
DirectAccess with HSA
cabp (0S9H)
Anthem Core
DirectAccess
cabr (0S9K)
Anthem Core
DirectAccess
with Child Dental
cdbr (0S9M)
Anthem Core
DirectAccess
caaa (0S9B)
Pathway
Pathway
Pathway
Pathway
$4,000 / $8,000
$4,300 / $8,600
$4,300 / $8,600
$5,750 / $11,500
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
20% / 50%
20% / 50%
20% / 50%
20% / 50%
$35 copay per visit for first
2 office visits, then deductible
and 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$40 copay per visit for first
2 office visits, then deductible
and 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Individual OOP Limit*
(Includes deductible, copays,
coinsurance & Rx. Family is 2 x
Individual amount)
Coinsurance*
Office Visit: PCP
Deductible and
20% coinsurance
Office Visit: Specialist
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$35 copay per visit for first
2 office visits, then deductible
and 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible
and 20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible
and 20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible
and 20% coinsurance
$500 copay then deductible
and 20% coinsurance
$50 copay then deductible
and 20% coinsurance
$200 copay
(waived if admitted)
then deductible
and 20% coinsurance
$500 copay then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Dental
Not covered
Not covered
Vision
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limited to 26 visits/year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limited to 26 visits/year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Pediatric dental included
Adult not inclcuded
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limited to 26 visits/year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Outpatient Diagnostic Tests
(Examples: X-ray, EKG)
Outpatient Advanced
Diagnostic Tests
(Examples: MRI, CT scan)
Preventive Care
Urgent Care
Emergency Room Care
Hospital:
Inpatient Admission
Hospital:
Outpatient Surgery
Hospital Facility
Maternity
RX Tier 1 (Retail)
RX Tier 2 (Retail)
RX Tier 3 (Retail)
RX Tier 4 (Retail)
Mental Health
Substance Abuse
Chiropractic
Physical Therapy
* Information denoted by asterisk shows in-network / out-of-network values
$20 copay
$50 copay
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Not covered
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limited to 26 visits/year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
6
Anthem Core
DirectAccess
caae (0S9D)
Anthem Core
DirectAccess with HSA
caar (0S9F)
Anthem Essential
DirectAccess
cbjc (0S9U)
Anthem Essential
DirectAccess
cbds (0S9Z)
Anthem Essential
DirectAccess with HSA
cbbg (0SA4)
Pathway
Pathway
Pathway
Pathway
Pathway
$6,050 / $12,100
$6,300 / $12,600
$1,750 / $3,500
$2,500 / $5,000
$3,000 / $6,000
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$6,350 / $12,700
$3,600 / $7,200
25% / 50%
0% / 30%
20% / 50%
10% / 40%
10% / 40%
Deductible and
0% coinsurance
Deductible and
0% coinsurance
$35 copay per visit for first
3 office visits, then deductible
and 20% coinsurance.
Other office services
subject to deductible and
20% coinsurance.
Deductible and
20% coinsurance
Deductible and
20% coinsurance
$40 copay per visit for first
3 office visits, then deductible
and 10% coinsurance.
Other office services
subject to deductible and
10% coinsurance.
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
25% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 25% coinsurance
$350 copay
(waived if admitted)
then deductible
and 25% coinsurance
$1,000 copay then deductible
and 25% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible
and 0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible
and 0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 10% coinsurance
$200 copay
(waived if admitted)
then deductible
and 10% coinsurance
$500 copay then deductible
and 10% coinsurance
$50 copay then deductible
and 10% coinsurance
$200 copay
(waived if admitted)
then deductible
and 10% coinsurance
$500 copay then deductible
and 10% coinsurance
Deductible and
25% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
$1,000 copay for inpatient
facility then deductible
and 25% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
$500 copay for inpatient
facility then deductible
and 10% coinsurance
$15 copay
$15 copay
$40 copay
$40 copay
Deductible and
25% coinsurance
Deductible and
25% coinsurance
$500 copay for inpatient
facility then deductible
and 20% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
$500 copay for inpatient
facility then deductible
and 10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Not covered
Not covered
Not covered
Not covered
Not covered
Pediatric vision included
Adult not included
Deductible and
25% coinsurance
Deductible and
25% coinsurance
Deductible and
25% coinsurance
(limited to 26 visits/year)
Deductible and
25% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limited to 26 visits/year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
20% coinsurance
Deductible and
20% coinsurance
Deductible and
20% coinsurance
(limited to 26 visits/year)
Deductible and
20% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
(limited to 26 visits/year)
Deductible and
10% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
(limited to 26 visits/year)
Deductible and
10% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
$45 copay per visit for first
2 office visits, then deductible
and 25% coinsurance.
Other office services
subject to deductible and
25% coinsurance.
Deductible and
25% coinsurance
Deductible and
25% coinsurance
$20 copay
$50 copay
Deductible and
0% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Deductible and
10% coinsurance
Anthem Off-Exchange Plans
Anthem Essential
DirectAccess
cbaa (0S9P)
Anthem Preferred
DirectAccess
ccab (0SA9)
Anthem Preferred
DirectAccess
with Child Dental
cdcp (0SAB)
Anthem Catastrophic
DirectAccess
(0S99)
Pathway
Pathway
Pathway
Pathway
$3,500 / $7,000
$750 / $1,500
$750 / $1,500
$6,350 / $12,700
$4,500 / $9,000
$6,000 / $12,000
$6,000 / $12,000
$6,350 / $12,700
0% / 30%
0% / 30%
0% / 30%
0% / 30%
$45 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
$30 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
$30 copay, unlimited.
Other office services
subject to deductible and
0% coinsurance.
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
$40 copay per visit for first
3 office visits, then deductible
and 0% coinsurance.
Other office services
subject to deductible and
0% coinsurance.
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
No cost to you
No cost to you
No cost to you
No cost to you
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible
and 0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible
and 0% coinsurance
$500 copay then deductible
and 0% coinsurance
$50 copay then deductible
and 0% coinsurance
$200 copay
(waived if admitted)
then deductible
and 0% coinsurance
$500 copay then deductible
and 0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
$500 copay for inpatient
facility then deductible
and 0% coinsurance
Deductible and
0% coinsurance
RX Tier 1 (Retail)
$15 copay
$15 copay
$15 copay
RX Tier 2 (Retail)
$40 copay
$40 copay
$40 copay
RX Tier 3 (Retail)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Dental
Not covered
Not covered
Vision
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limited to 26 visits/year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limited to 26 visits/year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Pediatric dental included
Adult not included
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limited to 26 visits/year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Network Name*
Individual Deductible*
(Family is 2 x Individual amount)
Individual OOP Limit*
(Includes deductible, copays,
coinsurance & Rx. Family is 2 x
Individual amount)
Coinsurance*
Office Visit: PCP
Office Visit: Specialist
Outpatient Diagnostic Tests
(Examples: X-ray, EKG)
Outpatient Advanced
Diagnostic Tests
(Examples: MRI, CT scan)
Preventive Care
Urgent Care
Emergency Room Care
Hospital:
Inpatient Admission
Hospital:
Outpatient Surgery
Hospital Facility
Maternity
RX Tier 4 (Retail)
Mental Health
Substance Abuse
Chiropractic
Physical Therapy
* Information denoted by asterisk shows in-network / out-of-network values
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Not covered
Pediatric vision included
Adult not included
Deductible and
0% coinsurance
Deductible and
0% coinsurance
Deductible and
0% coinsurance
(limited to 26 visits/year)
Deductible and
0% coinsurance
(limit of 20 visits per year,
network & non-network
are combined)
Notes
8
Exclusions and Limitations
Preventive care services consist of services recommended by the United States Preventive Services Task Force, including
well-child care, immunizations, PSA screenings, Pap tests, mammograms and more.
These plans also include out-of-network benefits for services rendered by providers located in Missouri; emergency care,
urgent care, and ambulance services; or services approved in advance by Anthem.
Covered physical therapy services performed in an office setting will have the same Primary Care Doctor office visit cost share
as listed in the above chart.
You may be able to get more cost-savings subsidies on Silver plans. Check with your Anthem authorized representative for
more information and to find out if you qualify for a tax credit or subsidy.
Exclusions
This list includes some of the more common services not covered by these plans:
}} For services rendered by providers located outside the State of Missouri unless:
1. The services are for emergency care, urgent care and ambulance services; or
2. The services are approved in advance by Anthem.
}} Acupuncture
}} Artificial insemination, fertilization, infertility drugs or sterilization reversal
}} Artificial and mechanical hearts
}} Alternative or complementary medicine
}} Bariatric surgery
}} Benefits covered by Medicare or a governmental program
}} Breast reduction or augmentation mammoplasty is excluded unless associated with breast reconstruction surgery following
a medically necessary mastectomy resulting from cancer
}} Care provided by a member of your family
}} Care received in an emergency room that is not emergency care, except as specified in your Contract
}} Charges incurred prior to the effective date of coverage or after the termination date of coverage
}} Charges greater than the maximum allowable amount (charges exceeding the amount Anthem recognizes for services)
}} Comfort and/or convenience items
}} Cosmetic surgery and/or treatment that’s primarily intended to improve your appearance
}} Custodial care
}} Dental, except as described in your Contract
}} Educational services
}} Experimental or investigative treatment
}} Infertility testing and treatment
}} Nutritional and dietary supplements
}} Over-the-counter drugs, devices or products
}} Pharmacy except as spelled out in your Contract
}} Routine foot care
}} Sclerotherapy (a medical procedure used to eliminate varicose veins and spider veins)
}} Services we determine aren’t medically necessary
}} Sex transformation surgery
}} TMJ and Craniomandibular Joint Disorders
}} Vision except as described in your Contract
}} Weight loss programs or treatment of obesity except as mandated
}} Workers’ compensation
Limitations
These services are limited as described below:
}} Accidental dental injury benefit limit – maximum of $3,000 per accident
}} Therapy services
–– Physical therapy – 20 visits per member per year
–– Occupational therapy – 20 visits per member per year
}} Chiropractic – 26 visits for manipulation per member per year
}} Rehabilitation
–– Cardiac – 36 visits
–– Pulmonary – 20 visits
–– Inpatient – 60 days
}} Home health care – 90 visits
}} Private duty nursing – 82 visits per year, 164 visits per lifetime
}} Skilled nursing facility – 90 days
}} Transplants – per transplant
–– Transportation and lodging – limited to $10,000
–– Donor search – limited to $30,000
Notes
10
In Missouri, (excluding 30 counties in the Kansas City area) Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT),
Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and
HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite
benefits. Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.