Page 6 - Open Sky BROCHURE - HOURLY 2021-2022
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9/1/2021-8/31/2022 Employee Benefits Brochure
Hourly
Medical Plans – Anthem Blue Cross
Your Copay/ Coinsurance Blue Classic 28 PPO Blue Classic 11 PPO
In-Network** In-Network**
Calendar Year Deductible:
Individual $5,000 $1,500
Family $10,000 $4,500
Annual Out of Pocket Maximum:
Individual $7,000 $4,500
Family $14,000 $9,000
Hospital Services:
Inpatient 30% coinsurance* 20% coinsurance*
Outpatient Surgery 30% coinsurance* 20% coinsurance*
Emergency Room $250 + 30% $250 + 20%
Physician Services:
Office Visit (PCP/Specialist) $30 / $60 $30 / $60
Urgent Care $60 $60
Chiro / Acupuncture / Massage $30 (20 visits per year) $30 (20 visits per year)
Preventive Care: No charge No charge
Prescription Drugs:
Rx Deductible None None
Tier 1 $15 $15
Tier 2 $50 $50
Tier 3 $75 $75
Tier 4 30% up to $350 max 30% up to $350 max
*Deductible applies.
**Please refer to carrier benefit summaries for more detailed information & out-of-network benefits.
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