Anthem CDHP - ES Represented Baltimore

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Out of NetworkCovered under MedicalCoverageAnthem CDHP - ES Rep BaltimoreAnnual physical examIn Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; check with Plan for detailsOut of Network100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsWell-woman exam (includes pap)In Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; check with Plan for detailsOut of Network100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsMammogramColonoscopyIn Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; age schedules apply;check with Plan for detailsOut of Network100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsIn Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; check with Plan for detailsOut of Network100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsCancer screeningsIn Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; check with Plan for detailsOut of Network100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsCardiovascular screeningsIn Network100% covered; not deducted from HRA account; mustmeet preventive guidelines; check with Plan for detailsOut of Network
100% covered; not deducted from HRA account;subject to Reasonable and Customary limits; mustmeet preventive guidelines; check with Plan for detailsAllergy tests and treatmentsFertility servicesIn vitro fertilizationArtificial inseminationFemale tubal ligationMale vasectomyOffice visit: Pre/postnatalIn Network90% covered after deductible is metOut of Network60% covered after deductible is met; subject toReasonable and Customary limitsIn Network90% covered after deductible is met; limited to$25,000 per lifetime including prescription drugs; inand out-of-network combinedOut of Network60% covered after deductible is met; limited to$25,000 per lifetime including prescription drugs; inand out-of-network combined; subject to R&C limitsIn Network90% covered after deductible is met; limited to$25,000 per lifetime for all fertility services combinedincluding prescription drugs; in and out-of-networkcombinedOut of Network60% covered after ded is met; limited to $25,000 perlifetime for all fertility services combined includingprescription drugs; in and out-of-network combined;subject to R&C limitsIn Network90% covered after deductible is met; limited to$25,000 per lifetime for all fertility services combinedincluding prescription drugs; in and out-of-networkcombinedOut of Network60% covered after deductible is met; limited to$25,000 per lifetime for all fertility services combinedincluding prescription drugs; in and out-of-networkcombined; subject to R&C limitsIn Network90% covered after deductible is metOut of Network60% covered after deductible is met; subject toReasonable and Customary limitsIn Network90% covered after deductible is metOut of Network60% covered after deductible is met; subject toReasonable and Customary limitsIn Network90% covered after deductible is metOut of Network60% covered after deductible is met; subject toReasonable and Customary limits
Page 1 and 2: Northrop Grumman Health PlanBenefit
Page 3: Out of Network90% covered after ded
Page 7 and 8: Detox: Inpatient coverageRehab: Out
Page 9 and 10: 60% covered after deductible is met

Anthem CDHP - ES Represented Baltimore

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