Page 7 - PetVet 2022 Master Benefits Guide_Final

Medical

PetVet offers comprehensive medical coverage through Anthem BlueCross
BlueShield. You have the choice between the following five medical plan options.

 1: PPO $1,000  3: $1,400 Deductible Plan with HSA  5: $6,000 Deductible Plan with HSA
 2: PPO $2,000  4: $3,000 Deductible Plan with HSA

Anthem BlueCross BlueShield Plan 1: PPO $1,000 Plan 2: PPO $2,000
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible (1/1 – 12/31)
Single $1,000 $2,000 $2,000 $4,000
Family $2,000 $4,000 $4,000 $8,000
Coinsurance 90% 60% 80% 50%
Calendar Year Out-of-Pocket Maximum (includes deductible)
Single $2,500 $5,000 $4,000 $8,000
Family $5,000 $10,000 $8,000 $16,000
Deductible and Out-of-Pocket Maximum
Embedded* Embedded*
Type
Services
Subject to Subject to
Preventive Care Covered at 100% deductible and Covered at 100% deductible and
coinsurance coinsurance
Subject to Subject to
Office Visit: Primary Care $20 per visit deductible and $25 per visit deductible and
coinsurance coinsurance
Subject to Subject to
Office Visit: Specialist $40 per visit deductible and $50 per visit deductible and
coinsurance coinsurance
Outpatient Surgery, Diagnostic and Subject to Subject to Subject to Subject to
Therapeutic Services deductible and deductible and deductible and deductible and
(CAT Scans, PET Scans, MRI) coinsurance coinsurance coinsurance coinsurance
Subject to Subject to Subject to Subject to
Hospital Stay deductible and deductible and deductible and deductible and
coinsurance coinsurance coinsurance coinsurance
$200 per visit, then $200 per visit, $200 per visit, then $200 per visit, then
Emergency Room
100% then 100% 100% 100%
Subject to Subject to
$40 per visit, then $50 per visit, then
Urgent Care deductible and deductible and
100% 100%
coinsurance coinsurance
 All benefits information outlined are subject to plan provisions and contract details. The highlighted
benefits are only a brief summary. Please refer to the Summary Plan Description (SPD) for full details.
 Embedded deductible means expenses for each covered family member are capped at the individual
deductible amount.
 Deductibles, Out-of-Pocket Maximums and frequencies will run on a calendar year basis (1/1 – 12/31)
 If you enroll in the PPO Copay plans, you are eligible to elect a Health Care Flexible Spending Account (FSA).

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