Page 8 - My FlipBook
P. 8
Beneit Resource
Guide
Anthem Plus Plan Anthem Base Plan
In-Network Out-of-Network In-Network Out-of-Network
Deductible $2,500 $2,500 $5,000 $10,000
(single/family) $5,000 $5,000 $10,000 $20,000
Out-of-pocket limit $5,000 $10,000 $6,600 $13,200
(single/family) $10,000 $20,000 $13,200 $26,400
Physician home and ofice services 20% 40% 30% 50%
(primary or specialist)
Preventive care services Covered at 100%, 40% Covered at 100%, 50%
no copay no copay
Emergency/urgent care 20%/20% 20%/40% 30%/30% 50%/50%
Inpatient and outpatient professional services 20% 40% 30% 50%
Inpatient facility services 20% 40% 30% 50%
Outpatient surgery hospital/alternative care 20% 40% 30% 50%
facility
Other outpatient services 20% 40% 30% 50%
Outpatient therapy services 20% 40% 30% 50%
Behavioral health services Copay/coinsurance based on setting where covered services are received
Human organ and tissue transplants 20% 40% 30% 50%
Prescription drugs—retail 20% 40% 30% 50%
Prescription drugs—mail order 20% Not covered 30% Not covered
Lifetime maximum Unlimited
All deductibles and coinsurance apply toward out-of-pocket maximum including prescription drugs; dependent age: to the end of the calendar year
which the child attains age 26
Medical Insurance Cost of Coverage
Anthem Plus Plan Anthem Base Plan
Monthly Employee Payroll Deduction Monthly Employee Payroll Deduction
Cost (24x) Cost (24x)
Employee $182.82 $91.41 $95.74 $47.87
Employee + spouse $755.12 $377.56 $579.92 $289.96
Employee + child(ren) $612.04 $306.02 $447.86 $223.93
Family $1,230.13 $615.07 $1,064.13 $532.07
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you can use; our deductible restarts
January 1 each year; dependent age: to the end of month which the child attains age 26
8
Guide
Anthem Plus Plan Anthem Base Plan
In-Network Out-of-Network In-Network Out-of-Network
Deductible $2,500 $2,500 $5,000 $10,000
(single/family) $5,000 $5,000 $10,000 $20,000
Out-of-pocket limit $5,000 $10,000 $6,600 $13,200
(single/family) $10,000 $20,000 $13,200 $26,400
Physician home and ofice services 20% 40% 30% 50%
(primary or specialist)
Preventive care services Covered at 100%, 40% Covered at 100%, 50%
no copay no copay
Emergency/urgent care 20%/20% 20%/40% 30%/30% 50%/50%
Inpatient and outpatient professional services 20% 40% 30% 50%
Inpatient facility services 20% 40% 30% 50%
Outpatient surgery hospital/alternative care 20% 40% 30% 50%
facility
Other outpatient services 20% 40% 30% 50%
Outpatient therapy services 20% 40% 30% 50%
Behavioral health services Copay/coinsurance based on setting where covered services are received
Human organ and tissue transplants 20% 40% 30% 50%
Prescription drugs—retail 20% 40% 30% 50%
Prescription drugs—mail order 20% Not covered 30% Not covered
Lifetime maximum Unlimited
All deductibles and coinsurance apply toward out-of-pocket maximum including prescription drugs; dependent age: to the end of the calendar year
which the child attains age 26
Medical Insurance Cost of Coverage
Anthem Plus Plan Anthem Base Plan
Monthly Employee Payroll Deduction Monthly Employee Payroll Deduction
Cost (24x) Cost (24x)
Employee $182.82 $91.41 $95.74 $47.87
Employee + spouse $755.12 $377.56 $579.92 $289.96
Employee + child(ren) $612.04 $306.02 $447.86 $223.93
Family $1,230.13 $615.07 $1,064.13 $532.07
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you can use; our deductible restarts
January 1 each year; dependent age: to the end of month which the child attains age 26
8
