[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-228333-en":3,"doc-seo-228333-105":30,"detail-sidebar-cat-0-en-105":97},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":4,"category_id":11,"category_name":12,"doc_title":13,"doc_description":14,"doc_content":15,"file_id":16,"file_url":17,"file_type":18,"file_size":19,"view_count":20,"is_deleted":4,"is_public":20,"is_downloadable":20,"audit_status":20,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":14,"update_tm":28,"read_time":29},228333,2336475104736,"วิน","https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222",7,"Healthcare","Anthem Blue Cross - 22-23 Benefits Summary","Plan benefits summary for Anthem Blue Cross SISC (Self Insured Schools of California) under a 100-B$0 Anthem Classic PPO with Prudent Buyer PPO network options. Outlines overall deductible and out-of-pocket limits by person and family, including how family embedded limits apply and how deductible carryover and in-network vs non-network calculations work. Lists coverage costs for preventive care, chronic condition preventive care, virtual care, specialist visits, and other practitioner services, distinguishing in-network and non-network/provider maximum-allowed reimbursements.","# Your summary of benefits\n\n## Anthem®Blue Cross\n\nYour Plan:SISC(Self Insured Schools of California):100-B$0 Anthem Classic PPO  \nYour Network:Prudent Buyer PPO  \n\n| Cost if you use a  \u003Cbr>Cost if you use an In-  \u003Cbr>Non-Network  \u003Cbr>Covered Medical Benefits  \u003Cbr>Network Provider  \u003Cbr>Provider   |  |  |\n| --- | --- | --- |\n| Overall Deductible   | $100 person /$300 family   |  |\n| Out-of-Pocket Limit   | $1,000 person/  \u003Cbr>$3,000 family   | No limit person /  \u003Cbr>No limit family   |\n| The family deductible and out-of-pocket maximum are embedded,meaning the cost shares of one family member will be  \u003Cbr>applied to both per person deductible and per person out-of-pocket maximum;in addition,amounts for all covered family  \u003Cbr>members apply to both the family deductible and family out-0f-pocket maximum.No one member will ay more than the per  \u003Cbr>person deductible or per person out-of-pocket maximum.Fourth quarter deductible carryover applies.  \u003Cbr>Your copays,coinsurance and deductible count toward your out of pocket amount(s).  \u003Cbr>In-network and out-of-network deductibles are combined and accumulate toward each other;however,in-network and out-of-  \u003Cbr>network out-of-pocket maximum amounts accumulate separately and do not accumulate toward each other.   |  |  |\n| Preventive Care/Screening/Immunization   | No charge   | Not covered   |\n| Preventive Care for Chronic Conditions per IRS guidelines   | No charge   | Not covered   |\n| Virtual Care(Telemedicine/Telehealth Visits)  \u003Cbr>Virtual Visits -Online visits with Doctors who also provide services in  \u003Cbr>person  \u003Cbr>Primary Care(PCP)  \u003Cbr>Mental Health and Substance Use Disorder care   | $0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply  \u003Cbr>$0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply   | All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(See footnote 1)  \u003Cbr>All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(See footnote 1)   |\n\nAnthem Blue Cross is the trade name of Blue Cross of Caliornia.Anthem Blue Cross and Anthem BlueCross Lie and Health InsuranceCompany are independent licensees ofthe Blue Cross Association.⑧ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the BlueCross Association.  \n\n| Cost if you use a  \u003Cbr>Cost if you use an In-  \u003Cbr>Non-Network  \u003Cbr>Covered Medical Benefits  \u003Cbr>Network Provider  \u003Cbr>Provider   |  |  |\n| --- | --- | --- |\n| Specialist   | $0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply   | All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(See footnote 1)   |\n| Medical Chats and Virtual (Video)Visits for Primary Care from our  \u003Cbr>Online Provider K Health,through its afiliated Provider groups   | No charge   |  |\n| Virtual Visits from Online Provider LiveHealth Online via  \u003Cbr>www.livehealthonline.com;our mobile app,website or Anthem-enabled  \u003Cbr>device  \u003Cbr>Primary Care(PCP)and Mental Health and Substance Use Disorder  \u003Cbr>Specialist Care   | No charge  \u003Cbr>$0 copay per visit deductible does not apply   |  |\n| Visits in an Office  \u003Cbr>Primary Care (PCP)  \u003Cbr>Specialist Care   | $0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply  \u003Cbr>$0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply   | All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(See footnote 1)  \u003Cbr>All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(See footnote 1)   |\n| Other Practitioner Visits  \u003Cbr>Retail Health Clinic  \u003Cbr>Manipulation Therapy  \u003Cbr>Pre-authorization review by American Specialty Health (ASH)is required  \u003Cbr>after the 5th visit).  \u003Cbr>Acupuncture  \u003Cbr>Coverage is limited to 12 visits per benefit period.   | $0 copay per visit  \u003Cbr>deductible does not  \u003Cbr>apply  \u003Cbr>0%coinsurance after  \u003Cbr>deductible is met  \u003Cbr>0%coinsurance after  \u003Cbr>deductible is met   | All billed amounts  \u003Cbr>exceeding the  \u003Cbr>maximum allowed  \u003Cbr>amount.  \u003Cbr>(S","cbCaimYZNGVzSwly","https://ap.wps.com/l/cbCaimYZNGVzSwly","pdf",524320,1,11,"English","en",105,"# Your Plan\n## Network\n# Cost Sharing\n## Deductible and Out-of-Pocket Limit\n# Covered Medical Benefits\n## Preventive Care and Chronic Conditions\n## Virtual Care\n## Specialist and Office Visits\n## Other Practitioner Visits\n## Other Services in an Office\n## Advanced Diagnostic Imaging (partial)","[{\"question\":\"What are the overall deductible and out-of-pocket limits for this plan?\",\"answer\":\"The overall deductible is $100 per person or $300 per family. The out-of-pocket limit is $1,000 per person and $3,000 per family, with embedded per-person limits inside the family totals.\"},{\"question\":\"How do preventive care and chronic condition preventive care work under the plan?\",\"answer\":\"Preventive care/screening/immunization shows no charge for covered benefits. Preventive care for chronic conditions per IRS guidelines is also no charge for covered benefits; non-network is not covered in the shown table.\"},{\"question\":\"How are virtual care and specialist visits covered for in-network vs non-network providers?\",\"answer\":\"Virtual visits (telemedicine/telehealth) have a $0 copay per visit with the deductible not applying for in-network, while non-network shows billing amounts exceeding the maximum allowed amount. Specialist visits have a $0 copay per visit with the deductible not applying for in-network, while non-network shows amounts exceeding the maximum allowed amount.\"}]","Anthem Blue Cross - 22-23 Benefits Summary | PDF",1789024979,28,{"code":4,"msg":31,"data":32},"ok",{"site_id":24,"language":23,"slug":33,"title":13,"keywords":34,"description":14,"schema_data":35,"social_meta":92,"head_meta":94,"extra_data":96,"updated_unix":28},"anthem-blue-cross-22-23-benefits-summary","",{"@graph":36,"@context":91},[37,54,74],{"@type":38,"itemListElement":39},"BreadcrumbList",[40,44,48,51],{"item":41,"name":42,"@type":43,"position":20},"https://docshare.wps.com","Home","ListItem",{"item":45,"name":46,"@type":43,"position":47},"https://docshare.wps.com/document/","Document",2,{"item":49,"name":12,"@type":43,"position":50},"https://docshare.wps.com/document/healthcare/",3,{"item":52,"name":13,"@type":43,"position":53},"https://docshare.wps.com/document/anthem-blue-cross-22-23-benefits-summary/228333/",4,{"url":52,"name":13,"@type":55,"image":56,"author":61,"headline":13,"publisher":63,"fileFormat":66,"inLanguage":23,"description":14,"dateModified":67,"datePublished":68,"encodingFormat":66,"isAccessibleForFree":69,"interactionStatistic":70},"DigitalDocument",{"url":57,"@type":58,"width":59,"height":60},"https://docshare.wps.com/thumbnails/anthem-blue-cross-22-23-benefits-summary/228333.png","ImageObject",300,407,{"name":9,"@type":62},"Person",{"url":41,"name":64,"@type":65},"DocShare","Organization","application/pdf","2026-09-11","2026-09-10",true,{"@type":71,"interactionType":72,"userInteractionCount":20},"InteractionCounter",{"@type":73},"ViewAction",{"@type":75,"mainEntity":76},"FAQPage",[77,83,87],{"name":78,"@type":79,"acceptedAnswer":80},"What are the overall deductible and out-of-pocket limits for this plan?","Question",{"text":81,"@type":82},"The overall deductible is $100 per person or $300 per family. The out-of-pocket limit is $1,000 per person and $3,000 per family, with embedded per-person limits inside the family totals.","Answer",{"name":84,"@type":79,"acceptedAnswer":85},"How do preventive care and chronic condition preventive care work under the plan?",{"text":86,"@type":82},"Preventive care/screening/immunization shows no charge for covered benefits. Preventive care for chronic conditions per IRS guidelines is also no charge for covered benefits; non-network is not covered in the shown table.",{"name":88,"@type":79,"acceptedAnswer":89},"How are virtual care and specialist visits covered for in-network vs non-network providers?",{"text":90,"@type":82},"Virtual visits (telemedicine/telehealth) have a $0 copay per visit with the deductible not applying for in-network, while non-network shows billing amounts exceeding the maximum allowed amount. Specialist visits have a $0 copay per visit with the deductible not applying for in-network, while non-network shows amounts exceeding the maximum allowed amount.","https://schema.org",{"og:url":52,"og:type":93,"og:title":13,"og:site_name":64,"og:description":14},"article",{"robots":95,"canonical":52},"index,follow",{"doc_id":7,"site_id":24},{"code":4,"msg":5,"data":98},[99,103,107,111,116,121,124,129,134,137,141],{"id":20,"doc_module":4,"doc_module_name":46,"category_name":100,"show_sort_weight":101,"slug":102},"Story & Novel",90,"story-novel",{"id":47,"doc_module":4,"doc_module_name":46,"category_name":104,"show_sort_weight":105,"slug":106},"Literature",80,"literature",{"id":53,"doc_module":4,"doc_module_name":46,"category_name":108,"show_sort_weight":109,"slug":110},"Exam",70,"exam",{"id":112,"doc_module":4,"doc_module_name":46,"category_name":113,"show_sort_weight":114,"slug":115},5,"Comic",60,"comic",{"id":117,"doc_module":4,"doc_module_name":46,"category_name":118,"show_sort_weight":119,"slug":120},6,"Technology",50,"technology",{"id":11,"doc_module":4,"doc_module_name":46,"category_name":12,"show_sort_weight":122,"slug":123},40,"healthcare",{"id":125,"doc_module":4,"doc_module_name":46,"category_name":126,"show_sort_weight":127,"slug":128},8,"Research & Report",30,"research-report",{"id":130,"doc_module":4,"doc_module_name":46,"category_name":131,"show_sort_weight":132,"slug":133},9,"Religion & Spirituality",20,"religion-spirituality",{"id":132,"doc_module":4,"doc_module_name":46,"category_name":135,"show_sort_weight":132,"slug":136},"World Cup","world-cup",{"id":138,"doc_module":4,"doc_module_name":46,"category_name":139,"show_sort_weight":138,"slug":140},10,"Lifestyle","lifestyle",{"id":142,"doc_module":4,"doc_module_name":46,"category_name":143,"show_sort_weight":112,"slug":144},19,"General","general"]