Page 3 - 3z.net.18 Employee Benefits

2018 Medical Benefits

Medical PLAN
Anthem BC/BS

You have the option to enroll in our group health insurance plan through Anthem BC/BS.

The benefits and your cost Blue Access Option 51 w/ Rx 7
(contribution) are outline in the
adjacent table. Benefits In-Network Out-of-Network
Annual Deductible
Individual/Family $2,000 / $6,000 $4,000 / $12,000

To check and see if your doctor is Out of Pocket Maximum
in your plan click on: Individual/Family $4,000 / $8,000 $8,000 / $16,000
(The out of pocket includes the
Anthem Provider Search annual deductible)

Lifetime Maximum Unlimited Unlimited
Preventive Services Paid at 100% Deductible + 40%
Manage your Anthem benefits on
line: PCP Office Visit $20 Copay Deductible + 40%
• Check benefits
• Manage Prescriptions Specialist Office Visit $40 Copay Deductible + 40%
• Estimate Costs
• View Claim Status Urgent Care $75 Copay Deductible + 40%
• File Appeal/Grievance
Emergency $250 Copay $250 Copay
Register:
Anthem On-Line Account Inpatient Deductible + 20% Deductible + 40%
Outpatient Services Deductible + 20% Deductible + 40%

Mental Health - Inpatient Deductible + 20% Deductible + 40%
Anthem Customer Service
800-382-5729 Mental Health - Outpatient $40 Copay Deductible + 40%

Hours: Short Term Rehabilitation $20 Copay Deductible + 40%
Mon-Fri 8:00AM – 6:00PM CST Outpatient
Prescriptions
(Generic/Preferred/Non-Preferred)
$10/$25/$40/25% The greater of $70
Retail – 30 day supply
up to $200 or 50%, min $70
$10/$65/$120/25%
Mail Order – 90 day supply Not Covered
up yo $200
Refer to Anthem’s detailed plan summary for limitations
Health Reimbursement Arrangement (HRA)
Coverage Election Deductible You Pay HRA
Employee Only $2000 $500 $1,500
Employee + Spouse $6,000 $1,500 $4,500
Employee + Child(ren) $6,000 $1,500 $4,500
Family $6,000 $1,500 $4,500

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.