You’ll pay less if you go to a doctor, hospital or pharmacy that is in network. See what’s covered for in-network and out-of-network care.
SEE WHAT THE PLAN PAYS FOR CARE
How Services Are Covered
|IN NETWORK||OUT OF NETWORK*|
|Here's What the Plan Pays|
|Preventive Care**||100% no deductible||65% after deductible (after $500 annual allowance)|
|Office Visits||85% after deductible||65% after deductible|
|Emergency Room||85% after deductible||85% after deductible|
|Hospital||85% after deductible||65% after deductible|
|Laboratory||85% after deductible||65% after deductible|
|X-Ray||85% after deductible||65% after deductible|
** Preventive care includes wellness visits for children, preventive exams and recommended screenings for adults and immunizations in or out of network.
IS YOUR PROVIDER IN NETWORK?
Although you can go to a doctor, hospital or pharmacy that is not in the network (out-of-network), you will pay less if you choose to go to one that is in the network.
- To see if your doctor is in the Anthem network, visit anthem.com or call 1-800-854-1834.
- If your doctor is not in the Anthem network, call 1-800-854-1834 and nominate your health care provider for possible inclusion.
- Search for doctors and health care facilities that are in the Hess Medical Plan network and compare them, based on location, cost and quality, using the Care & Cost Finder at anthem.com.
If no network provider is available where you need care, call Anthem—before receiving care—to approve using an out-of-network provider for in-network benefits. Without approval, you’ll receive out-of-network benefits.
What Happens If I Go Out of Network?
When you use an out-of-network provider, the plan will pay coinsurance based on Anthem’s maximum allowed amount. You are responsible for any portion of the provider’s charge that exceeds this amount. For example, if you have met your deductible, the plan will pay 65 percent of the maximum allowed amount for out-of-network care.
If your out-of-network provider charges $600 for a procedure and Anthem’s maximum allowed amount for the procedure is $500, you would pay 35 percent of the maximum allowed amount (35% x $500 = $175) plus the $100 that exceeds the maximum allowed amount, for a total of $275.