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Low HMO Plan High PPO PlanPlan Name Anthem Gold Vivity HMO 35/1000 Anthem Gold PPO 35/1000/20%IN-NETWORK BENEFITSDeductible (Employee/Family) $1,000 / $2,000 $1,000 / $3,000Coinsurance (Member/Carrier) 100%/0% 20% member/80% AnthemMaximum Out of Pocket Cost(MOOP)(Employee/Family) $6,700 / $13,500 $8,200 / $16,400Primary Care Provider (PCP)Copay $35 Deductible Waived $35 copayWellness & Preventative Covered at 100% Covered at 100%Specialist Copay $75 Deductible Waived $60 copayInpatient Hospitalization $750 copay 20% coinsurance after deductibleOutpatient Facility $500 copay $250 copay + Ded & coinsEmergency Room $500 copay $250 copay + Ded & coinsUrgent Care $35 Deductible Waived $35 copayLaboratory $25 copay Deductible Waived $15 copayX-Ray $25 copay Deductible Waived $15 copayImaging (CT, MRI, PET) $350 copay Deductible Waived $100 copay + Ded & coinsOUT-OF-NETWORK BENEFITSDeductible (Employee / Family)Emergency Only$2,000 / $4,000Coinsurance (Member / Carrier) 50% /50%Maximum Out of Pocket Cost(MOOP)(Employee / Family) $16,400 / $32,800PRESCRIPTION Rx BENEFITSGenericPreferred Brand Non-Preferred BrandTier 1: $20 CopayTier 2: $60 CopayTier 3: $135 CopayTier 4: $250 Copay Tier 1: Rx Ded + $15 CopayTier 2: Rx Ded + $70 CopayTier 3: Rx Ded + $120 CopayTier 4: Rx Ded + 40% ^ $250Rx Deductible N/A $300-Individual$600- FamilyClick Link for SBCHEALTH PLANSRefer to your Summary of BenefitCoverage (SBC) for full policy details,limitations, and exclusions.SBC (Plan Summary) SBC (Plan Summary)7
