Deductibles and Maximums
Deductibles
The annual deductible is $120 for one person, $240 for two people and $320 for three or more people.
Charges for non-covered services, penalties for not obtaining authorization, amounts over Customary and Reasonable, and flat dollar copayments (for example, for doctor's office visits, emergency room visits, or hospital admissions) do not apply toward the annual deductible.
Examples of How Copayments Work With the Annual Deductible
The following examples show how copayments affect the annual deductibles for three office visits — all three at network providers.
Visit #1 To a Primary Care Physician: Provider charges $100 for the office visit. The claim would be paid as follows:
Network Provider
Total Billed
$100
Amount Allowed For a PPO network participating provider (based on the negotiated discount)
$75
PCP Office Visit Copay
$10
Amount Applied to Calendar Year Deductible
$65
Calendar Year Deductible Remaining To be Met
$55
Amount Paid by the Plan
$0
Total Member Responsibility for this Visit
$75
Visit #2 To an OB/GYN Specialist: Provider charges $150 for the office visit. The claim would be paid as follows:
Network Provider
Total Billed
$150
Amount Allowed For a PPO network participating provider (based on the negotiated discount)
$100
Specialist Office Visit Copay
$20
Allowed Amount Remaining After Copay
$80
Amount Applied to Remaining Calendar Year Deductible which is Now Met
$55
Amount Paid by the Plan
$25
Total Member Responsibility for this Visit
$75
Visit #3 To a Dermatology Specialist: Provider charges $165 for the office visit. The claim would be paid as follows:
Network Provider
Total Billed
$165
Amount Allowed For a PPO network participating provider (based on the negotiated discount)
$125
Specialist Office Visit Copay
$20
Allowed Amount Remaining After Copay
$105
Amount Paid by the Plan
$105
Total Member Responsibility for this Visit
$20
Plan Maximums
Out-of-Pocket Maximum
The Plan has an out-of-pocket maximum that limits the amounts you pay for covered services. The out-of-pocket maximum is the maximum amount you pay each calendar year for covered expenses, including deductibles, copayments and coinsurance.
The annual out-of-pocket maximum is $750 per individual and $1,500 per family.
Charges for non-covered services, charges above Customary and Reasonable Charges (Eligible Expenses), and penalties for not obtaining pre-authorization do not apply toward the annual out-of-pocket maximum.
Lifetime Maximums
The Plan does not have an overall lifetime maximum benefit, but there are lifetime maximums for the following services or supplies:
Service or Supply
Lifetime Maximum
Infertility Treatments
$7,000 combined for all PG&E self-insured medical plans administered by Anthem Blue Cross or prior claims administrators.
Reimbursement for Travel and Lodging Expenses in connection with Organ Transplants
Transportation and lodging expenses for the transplant recipient and companion(s)
$10,000 combined for all travel expenses (IRS limit).
Reimbursement for Travel and Lodging Expenses incurred in connection with Bariatric/Transgender Surgery
$3,000 combined for all travel expenses.