Page 7 - Open Sky BROCHURE - HOURLY 2021-2022

9/1/2021-8/31/2022 Employee Benefits Brochure
Hourly

Medical Plans – Anthem Blue Cross

Mountain Enhanced
Your Copay/ Coinsurance H.S.A. PPO
HMO
In-Network Only In-Network**

Calendar Year Deductible:
Individual $1,000 $3,000

Family $3,000 $6,000

Annual Out of Pocket Maximum:
Individual $4,000 $5,000

Family $12,000 $10,000

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

Outpatient Surgery 30% coinsurance* 20% coinsurance*

Emergency Room 30% coinsurance* 20% coinsurance*

Physician Services:
Office Visit (PCP/Specialist) $30 / $50 20% coinsurance*

Urgent Care $50 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 $200 single / $400 family Combined with medical

Tier 1 $15 20% coinsurance*
Tier 2 $50* 20% coinsurance*
Tier 3 $75* 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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