Page 13 - Gray_2020 Benefit Guide
P. 13
Quick Contact Details:
PHONE: 888-650-4047
Your Health WEBSITE: anthem.com
ANTHEM Login to your Anthem
account at anthem.com
HEALTH Download Mobile Health in the
App Store or Google Play
INSURANCE
We’re pleased to offer two medical plan options administered through Anthem, a
provider of exceptional healthcare services. Once enrolled, you can visit anthem.com
to access claims payments, physician directories, ID cards and inquire about eligibility.
Dependent coverage can be obtained until the end of the month in which a child
turns 26.
CALENDAR YEAR BENEFITS HIGH DEDUCTIBLE PPO 2250 PLAN
Deductible (Single/Family) $3,000/$6,000 $2,250/ $6,750
Out-of-Pocket Maximum (Single/Family) $3,000/$6,000 $4,500/$9,000
Physician/Specialist Office Services Copay 0%/0% $20/$40
Inpatient Facility Coinsurance 0% 20%
Outpatient Surgery Facility Coinsurance 0% 20%
Emergency Room Services Copay/Coinsurance $0/$0 $75/0%
Urgent Care Services Copay/Coinsurance $0/$0 $40/0%
Lifetime Maximum Unlimited Unlimited
RX TIER All TIERS TIER 1 TIER 2 TIER 3 TIER 4
Rx - Retail Pharmacy 0% $10 $30 $60 25%
Rx - Mail Order Pharmacy 0% $20 $60 $120 25%
In-network Preventive Services are covered at 100% on both plans.
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