Page 9 - 2021 Master's University Benefit Brochure_Final3

Anthem H.S.A. PPO

This plan allows you to open a tax-free Health Savings Account (HSA), allowing you to pay for certain
medical expenses with money free from federal taxes. For additional information about an HSA visit
https://www.irs.gov/forms-pubs/about-publication-969

In-Network Out-Of-Network

Anthem Benefits Anthem Benefits
You Pay You Pay

$1,500 Individual / $3,000 Family $4,500 Individual / $9,000 Family
Annual Deductible (Family Individual Deductible $2,800) (Family Individual Deductible $4,500)

Annual Out-of-Pocket $3,000 Individual $9,000 Individual
Max $6,000 Family $18,000 Family
Office Visit
Primary Provider 10% after deductible 30% after deductible

Specialist 10% after deductible 30% after deductible

Preventive Services No charge 30% after deductible
10% after deductible 30% after deductible
Chiropractic Care
(30 visits per calendar year) (30 visits per calendar year)
Lab and X-ray
10% after deductible 30% after deductible
Advanced Imaging
Inpatient Hospitalization
10% after deductible 30% after deductible

Outpatient Surgery 10% after deductible 30% after deductible

Urgent Care 10% after deductible 30% after deductible

Durable Medical
Equipment 50% after deductible 50% after deductible

Emergency Room 10% after deductible 10% after deductible

Pharmacy $5/$15/$40/$60/30% up to $250 30% coinsurance up to $250
Subject to medical deductible Subject to medical deductible

The Master’s University & Seminary Page 8
2021 Employee Benefits Brochure