Page 19 - Skechers 2022 Benefits Guide

ANTHEM EPO
ANTHEM PPO SILVER
ANTHEM PPO GOLD
ANTHEM HSA PPO (HSA Eligible)
Your Cost Share Shown Below
Services
Physician Office Visits
Specialist Office Visits
LiveHealth Consultation
Preventative Services
Emergency Services (Waived if admitted)
Urgent Care Hospitalization
Outpatient Services
X-ray and Laboratory Services
Complex Radiology (MRI, PET, CT Scan)
Mental Health and Substance Abuse— Office Visit
Mental Health and Substance Abuse—Inpatient Visit
Prescription Dugs (30-Day Supply)
Generic
Name Brand Non-Formulary
Mail Order Prescription Drugs (90-Day Supply)
Generic
Name Brand Non-Formulary
In-Network Only
$30 Copay $50 Copay $0 Copay $0 Copay
$100 Copay
$50 Copay $250 Copay
$250 Copay
$40 Copay $150 Copay
$30 Copay ($0 Live Health)
$250 Copay
In-Network
$15 Copay $25 Copay $40 Copay
In-Network
$30 Copay $50 Copay $80 Copay
In-Network
$20 Copay $20 Copay $0 Copay $0 Copay
$150 Copay
$50 Copay 20% After Ded.
20% After Ded.
$40 Copay 20% After Ded.
$20 Copay ($0 Live Health)
20% After Ded.
In-Network
$15 Copay $25 Copay $40 Copay
In-Network
$30 Copay $50 Copay $80 Copay
Out-of-Network
40% After Ded. 40% After Ded. Not Covered 40% After Ded.
$150 Copay
40% After Ded. 40% After Ded.
40% After Ded.
40% After Ded. 40% After Ded.
40% After Ded. 40% After Ded.
Out-of-Network
$15 Copay + 40% $25 Copay + 40% $40 Copay +40%
Out-of-Network
Not Covered Not Covered Not Covered
In-Network
$25 Copay $35 Copay $0 Copay $0 Copay
$100 Copay
$50 Copay 10% After Ded.
10% After Ded.
10% After Ded. 10% After Ded.
$25 Copay ($0 Live Health)
10% After Ded.
In-Network
$15 Copay $25 Copay $40 Copay
In-Network
$30 Copay $50 Copay $80 Copay
Out-of-Network
40% After Ded. 40% After Ded. Not Covered 40% After Ded.
$100 Copay
40% After Ded. 40% After Ded.
40% After Ded. ($350 max)
40% After Ded. 40% After Ded.
40% After Ded. 40% After Ded.
Out-of-Network
$15 Copay + 40% $25 Copay + 40% $40 Copay +40%
Out-of-Network
Not Covered Not Covered Not Covered
In-Network
20% After Ded.
20% After Ded. $0 Copay After Ded. $0 Copay
20% After Ded.
20% After Ded. 20% After Ded.
20% After Ded.
20% After Ded. 20% After Ded.
20% After Ded. 20% After Ded.
In-Network
$15 Copay After Ded. $25 Copay After Ded. $40 Copay After Ded.
In-Network
$30 Copay After Ded. $50 Copay After Ded. $80 Copay After Ded.
Out-of-Network
40% After Ded. 40% After Ded. Not Covered 40% After Ded.
20% After Ded.
40% After Ded. 40% After Ded.
40% After Ded. ($350 max)
40% After Ded. 40% After Ded.
40% After Ded. 40% After Ded.
Out of Network (After Ded. for all levels)
$15 Copay + 40% $25 Copay + 40% $40 Copay +40%
Out-of-Network
Not Covered Not Covered Not Covered
*Available in all US states and Puerto Rico, excluding Hawaii.
2022 BENEFITS 19