Page 8 - PetVet 2022 Master Benefits Guide_Final

Medical

Anthem BlueCross Plan 3: $1,400 Deductible Plan 4: $3,000 Deductible Plan 5: $6,000 Deductible
BlueShield Plan with HSA Plan with HSA Plan with HSA
In-Network Out-of- In-Network Out-of- In-Network Out-of-
Network Network Network
Calendar Year Deductible (1/1 – 12/31)
Single $1,400 $2,650 $3,000 $6,000 $6,000 $10,000
Family $2,800 $5,200 $6,000 $12,000 $12,000 $20,000
Coinsurance 80% 50% 70% 50% 100% 70%
Calendar Year Out-of-Pocket Maximum (includes deductible)
Single $2,650 $5,200 $6,550 $12,000 $6,000 $12,000
Family $5,200 $10,400 $7,150 $24,000 $12,000 $24,000
Deductible and Out-of-Pocket
Aggregate* Aggregate* Embedded
Maximum Type
Services
Subject to Subject to Subject to
Covered at Covered at Covered at
Preventive Care deductible and deductible and deductible and
100% 100% 100%
coinsurance coinsurance coinsurance
Subject to Subject to Subject to Subject to Covered at Subject to
Office Visit: Primary Care deductible and deductible and deductible and deductible and 100% after deductible and
coinsurance coinsurance coinsurance coinsurance ded. coinsurance
Subject to Subject to Subject to Subject to Covered at Subject to
Office Visit: Specialist deductible and deductible and deductible and deductible and 100% after deductible and
coinsurance coinsurance coinsurance coinsurance ded. coinsurance
Outpatient Surgery,
Diagnostic and Therapeutic Subject to Subject to Subject to Subject to Covered at Subject to
Services (CT Scans, PET deductible and deductible and deductible and deductible and 100% after deductible and
Scans, MRI) coinsurance coinsurance coinsurance coinsurance ded. coinsurance
Subject to Subject to Subject to Subject to Covered at Subject to
Hospital Stay deductible and deductible and deductible and deductible and 100% after deductible and
coinsurance coinsurance coinsurance coinsurance ded. coinsurance

Subject to Covered as IN; Subject to Covered as IN; Covered at Covered as IN;
Emergency Room deductible and subject to ded. deductible and subject to ded. 100% after subject to ded.
coinsurance and coins. coinsurance and coins. ded. and coins.

Subject to Subject to Subject to Subject to Covered at Subject to
Urgent Care deductible and deductible and deductible and deductible and 100% after deductible and
coinsurance coinsurance coinsurance coinsurance ded. coinsurance

 Aggregate means there is one deductible that applies to all covered family members. Once expenses for
one person or any combination of 2 or more family members meet the deductible, the plan begins
paying coinsurance for all covered family members.
 If you enroll in the $1,400, $3,000, or $6,000 Deductible Plans with HSA, you are not eligible to elect a
Health Care Flexible Spending Account (FSA) , and you are eligible for a Health Savings Account (HSA).

8