Page 6 - Tacony 2021 Annual Benefits

Plan Details

Anthem
HDHP/HSA Plan PPO Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible Embedded Embedded
Individual $3,000 $6,000 $1,500 $3,000
Family $6,000 $12,000 $4,500 $9,000
Out-of-Pocket Maximum Embedded Embedded
Individual $6,000 $12,000 $4,500 $9,000
Family $12,000 $24,000 $13,500 $27,000
Physician Oice Visits
Primary Care 90% after deductible 60% after deductible $30 copay 60% after deductible
Specialist 90% after deductible 60% after deductible $60 copay 60% after deductible
Urgent Care
90% after deductible 60% after deductible $60 copay 60% after deductible
Wellness/Preventive
Oice Visit 100% no deductible 60% after deductible 100% no deductible 60% after deductible
Outpatient 100% no deductible 60% after deductible 100% no deductible 60% after deductible
Hospital Services
Inpatient 90% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 90% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room 90% after deductible $150 copay
Mental Health
Inpatient 90% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 90% after deductible 60% after deductible 80% after deductible 80% after deductible
Oice Visits 90% after deductible 60% after deductible $30 copay 60% after deductible
Substance Abuse
Inpatient 90% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 90% after deductible 60% after deductible 80% after deductible 60% after deductible
Chiropractic Care
90% after deductible 60% after deductible $30 PCP/$60 SCP 60% after deductible
Limitations 26 visits per calendar year 26 visits per calendar year
Prescription Drugs
Retail—Supply Limit 30 Days
Tier 1 90% after deductible 60% after deductible $15 copay 50% (minimum $60)
Tier 2 90% after deductible 60% after deductible $35 copay 50% (minimum $60)
Tier 3 90% after deductible 60% after deductible 20% up to $60 min/ 50% (minimum $60)
$100 max
Mail Order 90 days
Tier 1 90% after deductible Not covered $30 copay Not covered
Tier 2 90% after deductible Not covered $70 copay Not covered
Tier 3 90% after deductible Not covered 20% up to $120 min/ Not covered
$200 max

This is a high-level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is a
discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.

6 2021 Benefits Enrollment