Page 11 - SC Fuels EE Guide 2020 National

Medical Plan Choices

Anthem Blue Cross Anthem Blue Cross
Traditional PPO HDHP PPO

Network Name Prudent Buyer Non-Network PPO Network Non-Network
Plan Differences
Team Member Rate Per Paycheck
• Team Member Only $67.00 $49.50
• Team Member + Spouse 1 $192.00 $176.50
• Team Member + Child(ren) $148.00 $130.50
• Team Member + Family 1 $284.50 $241.00
Health Savings Account
- SC Fuels Contribution N/A P
Network
- Network Size AAA AAA
- In-Network Benefits P P
- Non-Network Benefits P P
Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Maximum Unlimited Unlimited
Calendar Year Deductible
• Individual $750 $1,500 $1,500 $3,000
• Family $2,250 $4,500 $3,000 $6,000
• Individual Protection Yes Yes No No
Out-of-Pocket Maximum Includes Rx Copays Includes Rx Copays
and Medical Deductible and Medical Deductibles
• Individual $3,500 $7,000 $3,500 $7,000
• Family $7,000 $14,000 $7,000 $14,000
• Individual Protection Yes Yes Yes Yes
Coinsurance (You Pay) 20% 40% 10% 40%
Office Visits
• Preventive Care No Charge Deductible, 40% No Charge Deductible, 40%
• PCP $25 Copay Deductible, 40% Deductible, 10% Deductible, 40%
• Specialist $35 Copay Deductible, 40% Deductible, 10% Deductible, 40%
• Urgent Care $50 Copay Deductible, 40% Deductible, 10% Deductible, 40%
• Virtual Visits $10 Copay N/A Deductible, 10% N/A
Hospitalization
• Inpatient Deductible, 20% Deductible, Deductible, 10% Deductible, 40%
$250 Copay, 40%
• Outpatient Surgery Deductible, 20% Deductible, Deductible, 10% Deductible, 40%
$250 Copay, 40%
Lab and X-Ray
• Physician Office $25 Copay PCP / Deductible, 40% Deductible, 10% Deductible, 40%
$35 Copay Specialist
• Diagnostic and Complex Deductible, 20% Deductible, 40% Deductible, 10% Deductible, 40%
Emergency Services Deductible, 20% Deductible, 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