Page 6 - Murphy Benefits Guide
P. 6
Plan Details
Premium Plan Regular Plan HSA Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $3,000 $2,000 $6,000 $3,000 $9,000
Family $2,000 $6,000 $4,000 $12,000 $6,000 $18,000
Out-of-Pocket Maximum (Includes deductible and copays)
Individual $4,000 $8,000 $5,000 $10,000 $5,500 $10,000
Family $8,000 $16,000 $10,000 $20,000 $11,000 $20,000
Physician Oice Visits
LiveHealth Online $15 copay Not covered $15 copay Not covered $15 after ded. Not covered
Primary Care $20 copay 50% after ded. $35 copay 50% after ded. $20 after ded. 40% after ded.
Specialist $40 copay 50% after ded. $70 copay 50% after ded. $40 after ded. 40% after ded.
Preventive
Covered at 100% 50% after ded. Covered at 100% 50% after ded. Covered at 100% 40% after ded.
Urgent Care
$75 copay 50% after ded. $75 copay 50% after ded. 20% after ded. 40% after ded.
Hospital Services
Inpatient 20% after ded. 50% after ded. 20% after ded. 50% after ded. 20% after ded. 40% after ded.
Outpatient 20% after ded. 50% after ded. 20% after ded. 50% after ded. 20% after ded. 40% after ded.
Emergency Room $200 copay, $200 copay, 20% after ded. 20% after ded. 20% after ded. 20% after ded.
plus 20% plus 20%
Prescription Drugs
Retail—Supply Limit 30 days 30 days 30 days
Tier 1 $10 copay 50% after ded. $10 copay 50% after ded. $10 copay 50% after ded.
Tier 2 $35 copay 50% after ded. $35 copay 50% after ded. $35 copay 50% after ded.
Tier 3 $75 copay 50% after ded. $60 copay 50% after ded. $60 copay 50% after ded.
Tier 4— 20% with $150 20% with $150 20% with $150
Specialty* max copay max copay max copay
Mail Order—Supply 90 days 90 days 90 days
Limit
Tier 1 $25 copay $25 copay $25 copay
Tier 2 $87.50 copay $87.50 copay $87.50 copay
Tier 3 $187.50 copay Not covered $150 copay Not covered $150 copay Not covered
Tier 4— 20% with $150 20% with $150 20% with $150
Specialty* max copay max copay max copay
Preventive Priced according to the tier in which Priced according to the tier in which Anthem’s preventive medication list
Medications they fall they fall is covered at 100%, no deductible
* Specialty Medications must be obtained through Anthem’s Specialty pharmacy network in order to receive network level beneits. Specialty
Medications are limited to a 30-day supply, regardless of whether they are retail or mail order.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
2020 Medical Contributions
Monthly Contributions
Premium Plan Regular Plan HSA Plan
Employee Only $280 $155 $85
Employee and Spouse $575 $320 $175
Employee and Child(ren) $560 $310 $170
Employee and Family $840 $460 $255
6 2020 Benefits Guide
Premium Plan Regular Plan HSA Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $3,000 $2,000 $6,000 $3,000 $9,000
Family $2,000 $6,000 $4,000 $12,000 $6,000 $18,000
Out-of-Pocket Maximum (Includes deductible and copays)
Individual $4,000 $8,000 $5,000 $10,000 $5,500 $10,000
Family $8,000 $16,000 $10,000 $20,000 $11,000 $20,000
Physician Oice Visits
LiveHealth Online $15 copay Not covered $15 copay Not covered $15 after ded. Not covered
Primary Care $20 copay 50% after ded. $35 copay 50% after ded. $20 after ded. 40% after ded.
Specialist $40 copay 50% after ded. $70 copay 50% after ded. $40 after ded. 40% after ded.
Preventive
Covered at 100% 50% after ded. Covered at 100% 50% after ded. Covered at 100% 40% after ded.
Urgent Care
$75 copay 50% after ded. $75 copay 50% after ded. 20% after ded. 40% after ded.
Hospital Services
Inpatient 20% after ded. 50% after ded. 20% after ded. 50% after ded. 20% after ded. 40% after ded.
Outpatient 20% after ded. 50% after ded. 20% after ded. 50% after ded. 20% after ded. 40% after ded.
Emergency Room $200 copay, $200 copay, 20% after ded. 20% after ded. 20% after ded. 20% after ded.
plus 20% plus 20%
Prescription Drugs
Retail—Supply Limit 30 days 30 days 30 days
Tier 1 $10 copay 50% after ded. $10 copay 50% after ded. $10 copay 50% after ded.
Tier 2 $35 copay 50% after ded. $35 copay 50% after ded. $35 copay 50% after ded.
Tier 3 $75 copay 50% after ded. $60 copay 50% after ded. $60 copay 50% after ded.
Tier 4— 20% with $150 20% with $150 20% with $150
Specialty* max copay max copay max copay
Mail Order—Supply 90 days 90 days 90 days
Limit
Tier 1 $25 copay $25 copay $25 copay
Tier 2 $87.50 copay $87.50 copay $87.50 copay
Tier 3 $187.50 copay Not covered $150 copay Not covered $150 copay Not covered
Tier 4— 20% with $150 20% with $150 20% with $150
Specialty* max copay max copay max copay
Preventive Priced according to the tier in which Priced according to the tier in which Anthem’s preventive medication list
Medications they fall they fall is covered at 100%, no deductible
* Specialty Medications must be obtained through Anthem’s Specialty pharmacy network in order to receive network level beneits. Specialty
Medications are limited to a 30-day supply, regardless of whether they are retail or mail order.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
2020 Medical Contributions
Monthly Contributions
Premium Plan Regular Plan HSA Plan
Employee Only $280 $155 $85
Employee and Spouse $575 $320 $175
Employee and Child(ren) $560 $310 $170
Employee and Family $840 $460 $255
6 2020 Benefits Guide
