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Insurance & costs

What this plan actually covers for Lyme care — and what you can claw back through superbills.

Your plan

Blue Shield of California PPO — Full PPO 20-250 100/70

Anthropic, PBC group plan · Effective Jan 1, 2026. This is a PPO — you can see anyone, but out-of-network costs more.

What you pay per year
Deductible
$250 / indiv.

Shared with family up to $750. What you pay before the plan kicks in for most services.

Out-of-pocket max
$2,250 in-network

$6,500 combined in/out. After this, insurance pays 100% of allowable amounts for the year.

What a typical Lyme visit costs

Copays assume you've met the $250 deductible. Before the deductible, you pay full allowable for services marked with CYD.

In-network doctor visit

Primary care, specialist, or behavioral health office visit.

$20 Covered

In-network labs (at a lab center)

LabCorp, Quest, Sonora Quest, etc. — routine panels.

$20 after $250 deductible Covered

Hospital outpatient dept: $0 after deductible. Cheapest route for big panels: have your doctor route the draw through the hospital lab.

Advanced imaging (MRI, CT, PET)

$0 after $250 deductible Prior auth required

Your provider has to call ahead and get it approved. Without prior auth, you pay full price.

Urgent care

$20 Covered

ER visit

$100 In or out-of-network

Waived if you're admitted — then it becomes the $0-after-deductible inpatient rate.

Out-of-network — the LLMD reality

Most Lyme-literate doctors don't take insurance. Here's how the money flows.

Out-of-network coinsurance

30% + anything over "allowable" Pay upfront

You pay the provider in full at the visit. Then submit a superbill to Blue Shield and get roughly 70% back of what Blue Shield considers "allowable" — after your $250 deductible is met.

Reality check: many LLMD visits run $400–600. "Allowable" is often far lower than what the doctor charges. Realistic reimbursement: $150–250 per visit, not 70% of what you paid.

Out-of-network mental health

10% + over allowable Better coverage

Parity law — mental health out-of-network is only 10% coinsurance on this plan (vs 30% for everything else). Applies to therapy, psychiatry, IOP.

Specialty labs (IGeneX, Galaxy)

~$300–500 per panel Mostly OOP

IGeneX and Galaxy are out-of-network specialty labs. Submit the invoice as an out-of-network claim — you might get partial reimbursement, but don't plan on it. Budget the full price.

Some labs offer a self-pay discount or payment plan. Ask before ordering.

Prescriptions

Plus Formulary, Rx Ultra network. No pharmacy deductible.

Tier 30-day 90-day
Tier 1 (generics)
$5
$15
Tier 2 (preferred brand)
$25
$75
Tier 3 (non-preferred)
$40
$120
Tier 4 (specialty)
30% up to $250
$750 cap

Common Lyme-treatment drugs

How to get reimbursed (superbill process)
  1. Pay the provider in full at the visit. Save the receipt and any lab invoices.
  2. Ask for a superbill. This is an itemized invoice that includes CPT codes (what was done), ICD-10 diagnosis codes (why), the provider's NPI, tax ID, and signature. Don't leave without it.
  3. Submit the claim to Blue Shield through the member portal at blueshieldca.com → Claims → Submit a claim. Or mail the paper form.
  4. Attach the superbill, the receipt showing you paid, and any notes that justify the care (for Lyme, a prior test result or referral helps).
  5. Wait 4–8 weeks. Blue Shield pays what they consider "allowable × 70%" after deductible, deposited to the account on file or mailed as a check.
  6. Appeal anything denied. Denials are often reversed on appeal, especially for medical necessity. Your LLMD can write a letter.
Keep a folder. One manila folder, or a Notes-app album of photos. Every superbill, every receipt, every denial letter. You'll want it all when tax season rolls around — medical expenses over 7.5% of AGI are deductible, and Lyme often pushes you past that threshold.
FSA / HSA notes

If you have an FSA or HSA through Anthropic, all of this qualifies — out-of-network LLMD visits, specialty labs, prescription co-pays, even supplements when prescribed by a doctor with a Letter of Medical Necessity.

FSA funds don't roll over — use them before year-end. HSA funds roll over indefinitely and can even be invested.

Pre-authorization — don't skip this

These services require prior authorization. Without it, you pay the whole bill:

Your provider handles the prior-auth call — but verify before the visit. "Did you get prior auth?" is a fair question at check-in.

What tests to get →