Page 3 - 2016 Open Enrollment
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Medical
Medical Plan Options
Anthem Blue Cross—Blue Access PPO & Blue Access Choice PPO
First Bank offers a preferred provider (PPO) network of coverage in all markets through Anthem Blue Cross
Blue Shield of Missouri. The PPO provides excellent access to in-network medical services and the lexibility to
go out-of-network when necessary. Two options of coverage are available in the PPO plan. The Option A plan
provides a higher level of coverage (i.e., more dollars) in exchange for a higher per pay period contribution from
participants. The Option B plan costs less per pay period, but requires higher copayments and deductibles when
services are received. The difference in these plans is entirely related to the cost structure; there is no difference in
the access to medical services or care given between these two plans.
Option A Plan Option B Plan
Covered Beneits Network Non-Network Network Non-Network
Deductible (single/family) $750/$1,500 $1500/$3,000 $1,500/$3,000 $4,500/$9,000
Coinsurance after deductible 15% 40% 20% 40%
Out-of-pocket limit (single/family) $2,500/$5,000 $5,000/$10,000 $4,500/$9,000 $9,000/$18,000
Physician services (primary care/ $25/$50 40% $30/$50 40%
specialist)
Emergency room
Copayment $150 $150 $250 $250
Coinsurance 15% 40% 20% 40%
Allergy injections
Copayment $5 40% $5 40%
Allergy testing
Coinsurance 15% 40% 20% 40%
Urgent care center services $50 40% $75 40%
Prescription Drugs—Retail (30-day supply)
Tier 1 (generic) $15 Not covered $15 Not covered
Tier 2 * 35% Not covered 35% Not covered
Tier 3 ** 50% Not covered 50% Not covered
Anthem Rx Direct Mail (90-day supply)
Tier 1 $30 Not covered $30 Not covered
Tier 2 $60 Not covered $60 Not covered
Tier 3 $100 Not covered $100 Not covered
* Preferred brand name drugs; minimum cost $25; maximum cost $75
** Non-preferred brand name drugs; minimum cost $45; maximum cost $100
2016 Open Enrollment
Medical
Medical Plan Options
Anthem Blue Cross—Blue Access PPO & Blue Access Choice PPO
First Bank offers a preferred provider (PPO) network of coverage in all markets through Anthem Blue Cross
Blue Shield of Missouri. The PPO provides excellent access to in-network medical services and the lexibility to
go out-of-network when necessary. Two options of coverage are available in the PPO plan. The Option A plan
provides a higher level of coverage (i.e., more dollars) in exchange for a higher per pay period contribution from
participants. The Option B plan costs less per pay period, but requires higher copayments and deductibles when
services are received. The difference in these plans is entirely related to the cost structure; there is no difference in
the access to medical services or care given between these two plans.
Option A Plan Option B Plan
Covered Beneits Network Non-Network Network Non-Network
Deductible (single/family) $750/$1,500 $1500/$3,000 $1,500/$3,000 $4,500/$9,000
Coinsurance after deductible 15% 40% 20% 40%
Out-of-pocket limit (single/family) $2,500/$5,000 $5,000/$10,000 $4,500/$9,000 $9,000/$18,000
Physician services (primary care/ $25/$50 40% $30/$50 40%
specialist)
Emergency room
Copayment $150 $150 $250 $250
Coinsurance 15% 40% 20% 40%
Allergy injections
Copayment $5 40% $5 40%
Allergy testing
Coinsurance 15% 40% 20% 40%
Urgent care center services $50 40% $75 40%
Prescription Drugs—Retail (30-day supply)
Tier 1 (generic) $15 Not covered $15 Not covered
Tier 2 * 35% Not covered 35% Not covered
Tier 3 ** 50% Not covered 50% Not covered
Anthem Rx Direct Mail (90-day supply)
Tier 1 $30 Not covered $30 Not covered
Tier 2 $60 Not covered $60 Not covered
Tier 3 $100 Not covered $100 Not covered
* Preferred brand name drugs; minimum cost $25; maximum cost $75
** Non-preferred brand name drugs; minimum cost $45; maximum cost $100
2016 Open Enrollment
