Medical Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family. Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.anthem.com.

FSA Eligible

	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,000 / $2,000	$3,000 / $6,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$5,000 / $10,000	$15,000 / $30,000
Primary Care	$30 Copay	Deductible + 50%
Routine Preventive	Fully Covered	Deductible + 50%
Specialist Visit	$70 Copay	Deductible + 50%
Physician Services	Deductible + 20%	Deductible + 50%
Inpatient Hospitalization	Deductible + 20%	Deductible + 50%
Outpatient Surgery	Deductible + 20%	Deductible + 50%
Basic Outpatient Diagnositcs	Deductible + 20%	Deductible + 50%
Urgent Care	$50 Copay	Deductible + 50%
Emergency Room	Deductible, then $300 Copay	Deductible, then $300 Copay

Prescription Drugs
Retail Prescriptions
Tier 1	$10
Tier 2	$35
Tier 3	$75
Tier 4	25% to $350
Mail Order Prescriptions
Tier 1	$20
Tier 2	$88
Tier 3	$188
Tier 4	25% to maximum of $350

	Monthly Cost
Employee Only	$174.71
Employee + Spouse	$992.71
Employee + Child(ren)	$664.71
Employee + Family	$1,482.71

Downloads

Plan Summary

Summary of Benefits and Coverage

Where Should I Go For Care

Preventive Care

Virtual Care

Wellbeing Solutions

HSA Eligible

	In-Network	Out-of-Network
Deductible (Individual/Family)	$3,300 / $6,600	$9,900 / $18,000
Member Coinsurance	0%	30%
Out-of-Pocket Max (Individual/Family)	$5,000 / $10,000	$15,000 / $30,000
Primary Care Visit	Deductible	Deductible + 30%
Routine Preventive	Fully Covered	Deductible + 30%
Specialist Visit	Deductible	Deductible + 30%
Physician Services	Deductible	Deductible + 30%
Inpatient Hospitalization	Deductible	Deductible + 30%
Outpatient Surgery	Deductible	Deductible + 30%
Basic Outpatient Diagnostics	Deductible	Deductible + 30%
Urgent Care	Deductible	Deductible + 30%
Emergency Room	Deductible	Deductible + 30%

Prescription Drugs
Retail Prescriptions
Tier 1	$10
Tier 2	$35
Tier 3	$75
Tier 4	25% to maximum of $350
Mail Order Prescriptions
Tier 1	$20
Tier 2	$88
Tier 3	$188
Tier 4	25% to $350

	Monthly Cost
Employee Only	$141.58
Employee + Spouse	$798.88
Employee + Child(ren)	$535.53
Employee + Family	$1,192.83