Page 7 - 2021 Dreyer's Benefits Guide

MEDICAL PLAN COMPARISON

ANTHEM BLUE CROSS MODIFIED
CLASSIC HMO ANTHEM BLUE CROSS CUSTOM EPO
Available in California ONLY Available in California & Outside of California
IN-NETWORK ONLY IN-NETWORK ONLY
HSA CONTRIBUTIONS
Employee Only N/A N/A
Family N/A N/A
CALENDAR YEAR DEDUCTIBLE
Individual $0 $750
Family $0 $2,250
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual $2,000 $3,000
Family $4,000 $6,000
YOU PAY YOU PAY
COINSURANCE / COPAYS
Office Visits $20/$40 copay $35/$70 copay
(PCP/SPC)
Lab Work Covered in full 20%
X-rays Covered in full 20%
Advanced Radiology $100 copay 20%
Hospital Services $250 copay per admit 20%
(Inpatient)
Hospital Services $125 copay 20%
(Outpatient)
Urgent Care $20 copay $35 copay
Emergency Room $100 copay 20%
Acupuncture $20 copay; 20 visits $35 copay; 20 visits
Chiropractic $20 copay; 20 visits $35 copay; 30 visits
PHARMACY
FORMULARY NAME Essential Drug List
RETAIL (UP TO 30-DAY SUPPLY)
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Generic $10 $10
Brand $35 30% up to $250 $35 30% up to $250
Non-Preferred $60 $60
Specialty 20% up to $250 20% up to $250
MAIL ORDER (UP TO 90-DAY SUPPLY)
Generic $20 $20
Brand $70 Not Covered $70 Not Covered
Non-Preferred $120 $120*

ANTHEM BLUE CROSS MODIFIED CLASSIC HMO
MONTHLY RATES EMPLOYER MONTHLY COST EMPLOYEE MONTHLY COST EMPLOYEE PER-PAY-PERIOD COST*
Employee Only $630.91 $411.91 $219.00 $109.50
* Employee contributions to insurance are deducted from the first two paychecks of each month. For those months with a third
paycheck, no insurance premiums will be deducted from the third paycheck.
Click here to view the complete Employee Contributions schedule for this plan.

ANTHEM BLUE CROSS CUSTOM EPO
MONTHLY RATES EMPLOYER MONTHLY COST EMPLOYEE MONTHLY COST EMPLOYEE PER-PAY-PERIOD COST*
Employee Only $602.52 $459.52 $143.00 $71.50
* Employee contributions to insurance are deducted from the first two paychecks of each month. For those months with a third
paycheck, no insurance premiums will be deducted from the third paycheck.
Click here to view the complete Employee Contributions schedule for this plan.
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MEDICAL PLANS