Page 12 - Apricity Benefits Guide

2020
Apricity Benefits Overview

MEDICAL PLAN SUMMARY

This chart provides a summary comparison of what you pay under the Anthem medical plan
options. For more detailed information, please refer to the plans’ summary plan descriptions.

Anthem Anthem Anthem
Beneit Core Plan Core Plus Plan HSA Plan
Description In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $3,000 $9,000 $1,000 $3,000 $2,000 $6,000
Family $9,000 $18,000 $3,000 $9,000 $6,000 $18,000
Out-of-Pocket Maximum
Individual $8,150 Unlimited $4,000 Unlimited $4,000 Unlimited
Family $16,300 Unlimited $12,000 Unlimited $8,000 Unlimited
Healthcare Services
Wellness/ Covered at 50% after Covered at 50% after Covered at 50% after
Preventive Visit no cost deductible no cost deductible no cost deductible
Primary Care $35 copay 50% after $25 copay 50% after 20% after 50% after
Visit deductible deductible deductible deductible
Specialist Visit $60 copay 50% after $50 copay 50% after 20% after 50% after
deductible deductible deductible deductible
First Stop Health Covered at Covered at No cost after deductible
(Telemedicine) no cost no cost
50% after
50% after
Urgent Care $35 copay deductible $25 copay deductible deductible deductible
50% after
20% after
Lab/X-Ray/ 40% after 50% after 20% after 50% after 20% after 50% after
Radiological deductible deductible deductible deductible deductible deductible
Services
Hospital Services $200 copay, $400 copay, $200 copay, $400 copay, 20% after 50% after
(Inpatient/ then 40% after then 50% after then 20% after then 50% after deductible deductible
Outpatient) deductible deductible deductible deductible
Emergency $200 copay, $200 copay, 20% after deductible
Room then 40% after deductible then 20% after deductible
Mental Health/ $200 copay, $400 copay, $200 copay, $400 copay, 20% after 50% after
Substance then 40% after then 50% after then 20% after then 50% after deductible deductible
Abuse deductible deductible deductible deductible
Inpatient/
Outpatient
Mental Health/ $35 copay 50% after $25 copay 50% after 20% after 50% after
Substance deductible deductible deductible deductible
Abuse Ofice
Visits
Skilled Nursing 40% after 50% after 20% after 50% after 20% after 50% after
Care deductible deductible deductible deductible deductible deductible
Home Health 40% after 50% after 20% after 50% after 20% after 50% after
Care deductible deductible deductible deductible deductible deductible
50% after
20% after
50% after
40% after
50% after
20% after
Hospice Care deductible deductible deductible deductible deductible deductible
Durable 40% after 50% after 20% after 50% after 20% after 50% after
Medical deductible deductible deductible deductible deductible deductible
Equipment
Chiropractic 40% after 50% after 20% after 50% after 20% after 50% after
Care deductible deductible deductible deductible deductible deductible
Outpatient 40% after 50% after 20% after 50% after 20% after 50% after
Therapies deductible deductible deductible deductible deductible deductible
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate, or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 12
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31