Page 11 - SC Fuels EE Guide 2020 Imperial & SD

Medical Plan Choices

SIMNSA Anthem Blue Cross Anthem Blue Cross
HMO Traditional PPO HDHP PPO

Network Name SIMNSA Prudent Non- PPO Non-
Buyer Network Network Network
Plan Differences
Team Member Rate Per Paycheck
• Team Member Only $26.86 $67.00 $49.50
• Team Member + Spouse 1 $130.60 $192.00 $176.50
• Team Member + Child(ren) $181.92 $148.00 $130.50
• Team Member + Family 1 $202.80 $284.50 $241.00
Health Savings Account
- SC Fuels Contribution N/A N/A P
Network
- Network Size A AAA AAA
- In-Network Benefits P P P
- Non-Network Benefits P P
Access to Providers PCP Managed Managed by You Managed by You
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Calendar Year Deductible
• Individual $0 $750 $1,500 $1,500 $3,000
• Family $0 $2,250 $4,500 $3,000 $6,000
• Individual Protection N/A Yes Yes No No
Out-of-Pocket Maximum Includes Rx Includes Rx Copays Includes Rx Copays
Copays and Medical Deductible and Medical Deductibles
• Individual $6,350 $3,500 $7,000 $3,500 $7,000
• Family $12,700 $7,000 $14,000 $7,000 $14,000
• Individual Protection N/A Yes Yes Yes Yes
Coinsurance (You Pay) 100% 20% 40% 10% 40%
Office Visits
• Preventive Care No Charge No Charge Ded, 40% No Charge Ded, 40%
• PCP $7 Copay $25 Copay Ded, 40% Ded, 10% Ded, 40%
• Specialist $7 Copay $35 Copay Ded, 40% Ded, 10% Ded, 40%
• Urgent Care $25 Copay $50 Copay Ded, 40% Ded, 10% Ded, 40%
• Virtual Visits Not Covered $10 Copay N/A Ded, 10% N/A
Hospitalization
• Inpatient No Charge Ded, 20% Ded, $250 Ded, 10% Ded, 40%
Copay, 40%
• Outpatient Surgery No Charge Ded, 20% Ded, $250 Ded, 10% Ded, 40%
Copay, 40%
Lab and X-Ray
• Physician Office No Charge $25 PCP / Ded, 40% Ded, 10% Ded, 40%
$35 Specialist
• Diagnostic / Complex No Charge Ded, 20% Ded, 40% Ded, 10% Ded, 40%
Emergency Services $250 Copay Ded, 20% Ded, 10%
1 Spouses who have other medical coverage available to them through their employer are not eligible to enroll in our plan.

TEAM MEMBER BENEFITS | 11