Page 7 - Centennial Enrollment

Medical Benefit Coverage—Anthem $2,700

QHDHP $2,700
In-Network Out-of-Network

Deductible

Individual $2,700 $4,000

Family $5,400* $8,000*

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

Individual $5,200 $6,000

Family $10,400** $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%

* Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the
calendar year. No one family member may contribute more than the individual deductible amount to the family deductible.
** Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-
pocket limit for the remainder of the calendar year. No one family member may contribute more than the individual maximum out-
of-pocket limit amount to the family maximum out-of-pocket limit. The out-of-pocket limit includes all copays, deductibles, and
coinsurance.

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