Page 6 - Great Circle 2021 Benefits Guide
P. 6
Plan Details
Plan 1 Plan 2 Plan 3
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $6,000 $12,000 $3,000 $4,000
Family $2,000 $4,000 $12,000 $24,000 $6,000 $8,000
Coinsurance
Meet deductible Meet the
80%/20% 60%/40% 90%/10% 50%/50% then 90% paid deductible
then 50%
by Great Circle
coinsurance
Out-of-Pocket Maximum
Individual $4,000 $10,000 $7,150 $12,700 $4,000 $8,000
Family $8,000 $20,000 $14,250 $25,400 $7,350 $16,000
Physician Oice Visits
Wellness/ Covered at Covered at Covered at
Preventive 100% 100% 100%
Primary Care $25 copay $25 copay Meet deductible
then 90% paid
Specialist $50 copay Meet deductible $50 copay Meet deductible Meet deductible Meet deductible
and 40% and 50% then 90% paid then 50%
LiveHealth $20 copay coinsurance $20 copay coinsurance $59 until coinsurance
Online deductible is
(telemedicine) met
Urgent Care $50 copay $50 copay Meet deductible
then 90% paid
Hospital Services
Inpatient Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible
and 20% and 40% and 10% and 50% then 50%
coinsurance coinsurance coinsurance coinsurance coinsurance
Outpatient Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible
and 20% and 40% and 10% and 50% then 90% paid then 50%
coinsurance coinsurance coinsurance coinsurance coinsurance
Emergency Meet deductible
Room $250 copay $250 copay $250 copay $250 copay then 90% paid
Blue Distinction Centers for Specialty Care
Blue Distinction Centers can help you and your doctor have a better informed discussion about inding the
right hospital for the speciic procedure you need. The Blue Distinction Center program evaluates hospitals
on their ability to deliver high-quality and safe specialty care based on criteria which directly impact patient
results—e.g., surgical team expertise and a history of better outcomes for patients. Hospitals receiving a Blue
Distinction Center+ designation are measured on how eficiently they deliver this high-quality patient care. Visit
www.anthem.com to learn more and locate a Blue Distinction center near you.
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Plan 1 Plan 2 Plan 3
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $6,000 $12,000 $3,000 $4,000
Family $2,000 $4,000 $12,000 $24,000 $6,000 $8,000
Coinsurance
Meet deductible Meet the
80%/20% 60%/40% 90%/10% 50%/50% then 90% paid deductible
then 50%
by Great Circle
coinsurance
Out-of-Pocket Maximum
Individual $4,000 $10,000 $7,150 $12,700 $4,000 $8,000
Family $8,000 $20,000 $14,250 $25,400 $7,350 $16,000
Physician Oice Visits
Wellness/ Covered at Covered at Covered at
Preventive 100% 100% 100%
Primary Care $25 copay $25 copay Meet deductible
then 90% paid
Specialist $50 copay Meet deductible $50 copay Meet deductible Meet deductible Meet deductible
and 40% and 50% then 90% paid then 50%
LiveHealth $20 copay coinsurance $20 copay coinsurance $59 until coinsurance
Online deductible is
(telemedicine) met
Urgent Care $50 copay $50 copay Meet deductible
then 90% paid
Hospital Services
Inpatient Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible
and 20% and 40% and 10% and 50% then 50%
coinsurance coinsurance coinsurance coinsurance coinsurance
Outpatient Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible Meet deductible
and 20% and 40% and 10% and 50% then 90% paid then 50%
coinsurance coinsurance coinsurance coinsurance coinsurance
Emergency Meet deductible
Room $250 copay $250 copay $250 copay $250 copay then 90% paid
Blue Distinction Centers for Specialty Care
Blue Distinction Centers can help you and your doctor have a better informed discussion about inding the
right hospital for the speciic procedure you need. The Blue Distinction Center program evaluates hospitals
on their ability to deliver high-quality and safe specialty care based on criteria which directly impact patient
results—e.g., surgical team expertise and a history of better outcomes for patients. Hospitals receiving a Blue
Distinction Center+ designation are measured on how eficiently they deliver this high-quality patient care. Visit
www.anthem.com to learn more and locate a Blue Distinction center near you.
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