Page 11 - 2016 Open Enrollment
P. 11
Pericient, Inc.
St. Louis Metro—Blue Access Choice PPO Network
All Other Locations—National PPO (Blue Card PPO)
PPO HSA
Network Out-of-Network Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $1,750 $3,500
Family $2,500 $5,000 $5,250 $10,500
Out-of-Pocket Maximum—Includes Deductible
Individual $3,700 $7,400 $3,425 $6,850
Family $9,250 $18,500 $6,850 $13,700
Physician Ofice Visits—Medical Copays Accumulate to the Out-of-Pocket Maximum
Primary care $30 copay 60% after deductible 80% after deductible 50% after deductible
Specialist $50 copay 60% after deductible 80% after deductible 50% after deductible
Telemedicine— $15 copay N/A 80% after deductible N/A
LiveHealth Online
Wellness/preventive 100% no deductible 60% after deductible 100% no deductible 50% after deductible
Hospital Services
Inpatient/outpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Urgent care $50 copay 60% after deductible 80% after deductible 50% after deductible
Emergency room $250 copay 80% after deductible 80% after deductible
Prescription Drugs
Retail Supply Limit
Tier 1 $10 copay $10 copay 80% after deductible 80% after deductible
Tier 2 $30 copay $30 copay 80% after deductible 80% after deductible
Tier 3 $60 copay $60 copay 80% after deductible 80% after deductible
Tier 4 25% to $100 max 25% to $100 max 80% after deductible 80% after deductible
Mail Order—Supply Limit
Tier 1 $25 copay 80% after deductible
Tier 2 $75 copay Not covered 80% after deductible Not covered
Tier 3 $150 copay 80% after deductible
Tier 4 25% to $250 max 80% after deductible
2016 Medical/Rx Employee PPO HSA For a comprehensive listing of eligible,
Contributions per Pay Period routine preventive care services that
Employee Only $84.79 $62.49 are paid at 100 percent, log onto
Employee + Spouse $222.74 $164.45 www.anthem.com or call Anthem’s
Employee + Child(ren) $165.17 $119.83 customer service. For an interactive
Employee + Family $305.23 $218.18 tutorial on how the Anthem plans work,
log onto www.anthem.com/basics.
For maintenance medication: Mail order program is required after
receiving two reills from retail pharmacy.
11
St. Louis Metro—Blue Access Choice PPO Network
All Other Locations—National PPO (Blue Card PPO)
PPO HSA
Network Out-of-Network Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $1,750 $3,500
Family $2,500 $5,000 $5,250 $10,500
Out-of-Pocket Maximum—Includes Deductible
Individual $3,700 $7,400 $3,425 $6,850
Family $9,250 $18,500 $6,850 $13,700
Physician Ofice Visits—Medical Copays Accumulate to the Out-of-Pocket Maximum
Primary care $30 copay 60% after deductible 80% after deductible 50% after deductible
Specialist $50 copay 60% after deductible 80% after deductible 50% after deductible
Telemedicine— $15 copay N/A 80% after deductible N/A
LiveHealth Online
Wellness/preventive 100% no deductible 60% after deductible 100% no deductible 50% after deductible
Hospital Services
Inpatient/outpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Urgent care $50 copay 60% after deductible 80% after deductible 50% after deductible
Emergency room $250 copay 80% after deductible 80% after deductible
Prescription Drugs
Retail Supply Limit
Tier 1 $10 copay $10 copay 80% after deductible 80% after deductible
Tier 2 $30 copay $30 copay 80% after deductible 80% after deductible
Tier 3 $60 copay $60 copay 80% after deductible 80% after deductible
Tier 4 25% to $100 max 25% to $100 max 80% after deductible 80% after deductible
Mail Order—Supply Limit
Tier 1 $25 copay 80% after deductible
Tier 2 $75 copay Not covered 80% after deductible Not covered
Tier 3 $150 copay 80% after deductible
Tier 4 25% to $250 max 80% after deductible
2016 Medical/Rx Employee PPO HSA For a comprehensive listing of eligible,
Contributions per Pay Period routine preventive care services that
Employee Only $84.79 $62.49 are paid at 100 percent, log onto
Employee + Spouse $222.74 $164.45 www.anthem.com or call Anthem’s
Employee + Child(ren) $165.17 $119.83 customer service. For an interactive
Employee + Family $305.23 $218.18 tutorial on how the Anthem plans work,
log onto www.anthem.com/basics.
For maintenance medication: Mail order program is required after
receiving two reills from retail pharmacy.
11
