Page 9 - WesternU Sample Guide

Medical Plans

Anthem Blue Cross Anthem Blue Cross
Plan Name HMO PPO

Network Name [Network Name] [Network Name] Non-Network
Plan Differences
Employee Premiums $ $$

Health Savings Account
- Acorns Funded ✓
✓

Employee Cost Sharing Contribution, Copay Contribution, Deductible, Copay, Coinsurance

Network
- Network Size  
✓ ✓
- In-Network Benefits
✓
- Non-Network Benefits
Access to Providers Managed by Your PCP Managed by You
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Calendar Year Deductible
- Individual $0 $500 $1,000
- Family $0 $1,000 $2,000
Out-of-Pocket Maximum
- Individual $2,000 $4,000 $8,000
- Family $4,000 $8,000 $16,000
Coinsurance (Plan Pays) 100% 80% 60%
Office Visit Copay
- Preventive Care No Charge No Charge Deductible, 40%
- Primary Care Physician $20 Copay $20 Copay Deductible, 40%
- Specialist $40 Copay $20 Copay Deductible, 40%
- Urgent Care $20 Copay $20 Copay Deductible, 40%
- [Telemedicine Name] $50 Copay $50 Copay N/A
Hospitalization
- Inpatient $350 Copay Deductible, 20% $250/Admit, 40%
- Outpatient Surgery $175 Copay Deductible, 20% Deductible, 40%

Lab and X-Ray
- Diagnostic No Charge Deductible, 20% Deductible, 40%
- Complex $100 Copay Deductible, 20% Deductible, 40%
Emergency Services $150 Copay Deductible, $150 Copay, 20%
Chiropractic $10 Copay $30 Copay Deductible, 40%

Max 20 Visits/Year Max 20 Visits/Year