Page 9 - Future Steps
P. 9
Option 1
(California Residents Only) Option 2 Option 3 Option 4
HMO Plan Exclusive Classic PPO Plan HRA Plan HSA Plan
Network Only Network Non-Network Network Non-Network Network Non-Network
Employer Funding
Individual None None $750 $750
Family None None $1,500 $1,500
Calendar Year Deductible Non-Embedded Non-Embedded Non-Embedded
Individual $0 $0 $3,500 $1,500 $3,000 $2,500 $5,000
Family $0 $0 $7,000 $3,000 $6,000 $5,000 $10,000
Out-of-Pocket Maximum Embedded Embedded Embedded Embedded
Individual $3,000 $2,500 $10,000 $3,500 $7,000 $5,000 $10,000
Family $6,000 $5,000 $20,000 $7,000 $14,000 $10,000 $20,000
Physician Ofice Visits
Primary Care $20 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Specialist $40 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Wellness/Preventive Services 100%, no cost share 100%, 50% after deductible 100%, 70% after deductible 100%, 70% after deductible
no cost share no cost share no cost share
Hospital Services
Inpatient $250 copay per day (3 day $500 copay 50% after deductible 90% after deductible 70% after deductible 100% after deductible 70% after deductible
max)
Outpatient $125 copay per admission $250 copay 50% after deductible 90% after deductible 70% after deductible 100% after deductible 70% after deductible
Emergency Room $150 copay $100 copay $100 Copay 90% after deductible 90% after deductible 100% after deductible 100% after deductible
Urgent Care Facility $20 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Prescription Medications
Retail
Tier 1 $15 copay $10 copay Copay + 50% $10 copay* 30% of allowed + excess $10 copay** 30% of allowed + excess*
Tier 2 $30 copay $30 copay Copay + 50% $30 copay* 30% of allowed + excess $30 copay** 30% of allowed + excess*
Tier 3 $50 copay $50 copay Copay + 50% $50 copay* 30% of allowed + excess $50 copay** 30% of allowed + excess*
Tier 4 30% to $150 max 30% to $150 max Copay + 50% 30% to $150 max* 30% of allowed + excess 30% to $150 max** 30% of allowed + excess*
Home Delivery
Tier 1 $15 copay $10 copay Not covered $10 copay* Not covered $10 copay** Not covered
Tier 2 $60 copay $60 copay Not covered $60 copay* Not covered $60 copay** Not covered
Tier 3 $100 copay $100 copay Not covered $100 copay* Not covered $100 copay** Not covered
Tier 4 30% to $300 max 30% to $300 max Not covered 30% to $300 max* Not covered 30% to $300 max** Not covered
* Deductible waived. ** Applies after deductible has been met.
Medical Contributions—Bi-Weekly
HMO PPO HRA HSA
Employee $19.38 $29.23 $14.54 $0.00
Employee + Spouse $42.65 $64.30 $30.53 $0.00
Employee + Children $34.89 $52.61 $26.17 $0.00
Family $60.09 $90.60 $46.52 $0.00
Beginning January 1, 2018, VER will implement a tobacco use premium on all plans. Telephonic and
online support for tobacco cessation are provided through the Anthem employee assistance program,
Live Tobacco Free. Visit www.anthemeap.com and enter “VER” or call 800.999.7222 for more
details on becoming tobacco free.
9
(California Residents Only) Option 2 Option 3 Option 4
HMO Plan Exclusive Classic PPO Plan HRA Plan HSA Plan
Network Only Network Non-Network Network Non-Network Network Non-Network
Employer Funding
Individual None None $750 $750
Family None None $1,500 $1,500
Calendar Year Deductible Non-Embedded Non-Embedded Non-Embedded
Individual $0 $0 $3,500 $1,500 $3,000 $2,500 $5,000
Family $0 $0 $7,000 $3,000 $6,000 $5,000 $10,000
Out-of-Pocket Maximum Embedded Embedded Embedded Embedded
Individual $3,000 $2,500 $10,000 $3,500 $7,000 $5,000 $10,000
Family $6,000 $5,000 $20,000 $7,000 $14,000 $10,000 $20,000
Physician Ofice Visits
Primary Care $20 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Specialist $40 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Wellness/Preventive Services 100%, no cost share 100%, 50% after deductible 100%, 70% after deductible 100%, 70% after deductible
no cost share no cost share no cost share
Hospital Services
Inpatient $250 copay per day (3 day $500 copay 50% after deductible 90% after deductible 70% after deductible 100% after deductible 70% after deductible
max)
Outpatient $125 copay per admission $250 copay 50% after deductible 90% after deductible 70% after deductible 100% after deductible 70% after deductible
Emergency Room $150 copay $100 copay $100 Copay 90% after deductible 90% after deductible 100% after deductible 100% after deductible
Urgent Care Facility $20 copay $30 copay 50% after deductible $20 copay* 70% after deductible $20 copay** 70% after deductible
Prescription Medications
Retail
Tier 1 $15 copay $10 copay Copay + 50% $10 copay* 30% of allowed + excess $10 copay** 30% of allowed + excess*
Tier 2 $30 copay $30 copay Copay + 50% $30 copay* 30% of allowed + excess $30 copay** 30% of allowed + excess*
Tier 3 $50 copay $50 copay Copay + 50% $50 copay* 30% of allowed + excess $50 copay** 30% of allowed + excess*
Tier 4 30% to $150 max 30% to $150 max Copay + 50% 30% to $150 max* 30% of allowed + excess 30% to $150 max** 30% of allowed + excess*
Home Delivery
Tier 1 $15 copay $10 copay Not covered $10 copay* Not covered $10 copay** Not covered
Tier 2 $60 copay $60 copay Not covered $60 copay* Not covered $60 copay** Not covered
Tier 3 $100 copay $100 copay Not covered $100 copay* Not covered $100 copay** Not covered
Tier 4 30% to $300 max 30% to $300 max Not covered 30% to $300 max* Not covered 30% to $300 max** Not covered
* Deductible waived. ** Applies after deductible has been met.
Medical Contributions—Bi-Weekly
HMO PPO HRA HSA
Employee $19.38 $29.23 $14.54 $0.00
Employee + Spouse $42.65 $64.30 $30.53 $0.00
Employee + Children $34.89 $52.61 $26.17 $0.00
Family $60.09 $90.60 $46.52 $0.00
Beginning January 1, 2018, VER will implement a tobacco use premium on all plans. Telephonic and
online support for tobacco cessation are provided through the Anthem employee assistance program,
Live Tobacco Free. Visit www.anthemeap.com and enter “VER” or call 800.999.7222 for more
details on becoming tobacco free.
9
