Page 6 - Centennial Enrollment

Medical Benefit Coverage—Anthem $1,500

QHDHP $1,500
In-Network Out-of-Network

Deductible

Individual $1,500 $3,000

Family $3,000* $6,000*

Coinsurance 20% 40%
Out of Pocket Maximum (includes deductible and copays)

Individual $3,000 $6,000

Family $6,000** $12,000**

Office visit Deductible/80% Deductible/60%

Specialist Deductible/80% Deductible/60%

Emergency room Deductible/80% Network Deductible/80%

Routine preventive Covered at 100% Deductible/60%

Inpatient hospital Deductible/80% Deductible/60%

* No one in the family (employee plus one of more dependent) is eligible for benefits until the family coverage deductible is met.
** If family (employee plus one or more dependents) coverage is elected, the individual out-of-pocket maximum does not apply;
exceptions may apply.

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