CAP Medical at a Glance
Comprehensive Access Plan (CAP) Administered by Anthem Blue Cross
General
May use provider of choice (may experience savings with Anthem PPO network providers).
Annual deductible:
  • $120/person; $240/two people; $320/three or more people
Annual out-of-pocket maximum (includes deductible):
  • $750/person; no more than $1,500/family
No lifetime maximum.
No pre-existing condition exclusions.
All plan benefits and out-of-pocket maximums are based on Eligible Expenses only.
  • For the definition of "Eligible Expenses," see the Definitions section.
Hospital Stay
100% after a $100 copayment; pre-authorization required for non-emergency care, $300 penalty if not obtained; covers semi-private room (private if Medically Necessary); includes intensive care.
Skilled Nursing Facility
(For more information on custodial care, see "What the CAP Doesn't Cover.")
90% for semi-private room after 3 days in hospital; pre-authorization required, $300 penalty if not obtained. Excludes custodial care.
Emergency Room
$35 copay/visit for medical emergencies; waived if admitted. Lab/X-ray covered separately.
Outpatient Hospital care
$35 copay/visit for outpatient care; waived if admitted. Lab/X-ray covered separately
Maternity Care
Covered as any other condition. Pre-authorization required for delivery stays beyond 48 hours for normal delivery (96 hours for cesarean section); $300 penalty if not obtained.
Well-Baby Care
Covered as any other condition.
Office Visits
  • Primary care — $10 copay/visit
  • Specialist (including OB/GYN) — $20 copay/visit
Urgent Care Visits
  • Primary care - $10 copay/visit
  • Specialist (including OB/GYN) — $20 copay/visit
Routine Physical Examinations
  • Primary care — $10 copay/visit
  • Specialist $20 copay/visit
  • Lab/X-ray covered separately
Immunizations and Injections
95%
Eye Examinations
Not covered.
X-rays and Lab Tests
90%
Pre-Admission Testing
95%
Home Health Care and Home Hospice Care
90%; requires prior authorization; $300 penalty if not obtained. Excludes custodial care1
Outpatient Physical Therapy
80%
Outpatient Prescription Drugs
Covered by separate drug plan administered by Express Scripts, Inc. See Prescription Drug Benefits in this section of the Handbook for details.
Inpatient and Outpatient Mental Health Care
Covered by separate Mental Health Program administered by ValueOptions. See the Mental Health and Substance Abuse Coverage section.
Inpatient and Outpatient Substance Abuse Care
Covered by separate Substance Abuse Program administered by ValueOptions. See the Mental Health and Substance Abuse Coverage section.
Durable Medical Equipment
80%; pre-authorization required for purchase or cumulative rental over $1,000; $300 penalty if not obtained.
Chiropractic Care
80% for Medically Necessary care only; pre-authorization by American Specialty Health Network (ASHN) required after initial visit.
Acupuncture
80% for up to 20 visits per year from licensed acupuncturist or M.D.
Hearing Aids and related expenses
Covered effective January 1, 2014
80% for Medically Necessary only; one hearing aid per ear every three years
Other Benefits
Infertility—Paid according to type of benefit; $7,000 lifetime maximum. Balances from prior plans carry forward.
Transplant Services—100% when performed at a Center of Medical Excellence (CME) or approved facility only; pre-authorization required for all transplant services.