Page 4 - 2021 Open Sky Employee Benefits - SALARIED

12/1/2020-11/30/2021 Employee Benefits Brochure
Salaried

Medical Plans – Anthem Blue Cross

Your Copay/ Coinsurance Blue Classic 28 PPO H.S.A. PPO

In-Network In-Network

Calendar Year Deductible:
Individual $5,000 $3,000

Family $10,000 $6,000

Annual Out of Pocket Maximum:
Individual $7,000 $5,000

Family $14,000 $10,000

Hospital Services:
Inpatient 30% coinsurance* 20% coinsurance*

Outpatient Surgery 30% coinsurance* 20% coinsurance*

Emergency Room $400 / visit 20% coinsurance*

Physician Services:
Office Visit (PCP/Specialist) $30 / $60 20% coinsurance*

Urgent Care $60 20% coinsurance*

Chiro / Acupuncture / Massage $30 (20 visits per year) 20% coinsurance* (20 visits per year)

Preventive Care: No charge No charge

Prescription Drugs:
Rx Deductible None Combined with medical

Tier 1 $15 20% coinsurance*
Tier 2 $50 20% coinsurance*
Tier 3 $70 20% coinsurance*
Tier 4 30% up to $350 max 20% coinsurance*

*Deductible applies.
Please refer to carrier benefit summaries for more detailed information & out-of-network benefits.

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