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YOUR HEAL TH Login to your Anthem
account at anthem.com
Anthem Health Insurance
Download Mobile Health in the
App Store or Google Play

888.650.4047 | anthem.com

We’re pleased to offer two medical plan options administered through Anthem, a provider of
exceptional healthcare services. Both plans cover preventative care at 100%. The deductibles for
both plans are embedded, meaning only the individual deductible must be met by one person for
Anthem to begin paying coinsurance for that person.

The out-of-pocket-maximums work the same way. Deductibles and out-of-pocket maximums are
calculated on a plan year basis, January 1 - December 31. 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%

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