Page 8 - First Presbyterian Church Benefit Guide
P. 8
Medical Plan Highlights
Anthem Blue Cross Anthem Blue Cross
Plan Name PS-Classic HMO V-Classic HMO
Network Name Priority Select HMO Vivity HMO
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual None None
- Family None None
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $20 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay
- Urgent Care $20 Copay $20 Copay
- Telemedicine $49 copay $20 copay
Out-of-Pocket Maximum
- Individual $2,000 $2,000
- Family $4,000 $4,000
Hospitalization
- Inpatient $250 Copay $250 Copay
- Outpatient Surgery $125 Copay $125 Copay
Lab and X-Ray
- Diagnostic No Charge No Charge
- Advanced Imaging $100 Copay per Test $100 Copay per Test
Emergency Services $100 Copay $100 Copay
Chiropractic $20 Copay $20 Copay
60 Days/Year 60 Days/Year
*Limits apply. See SBC for details.
Your cost per paycheck
15th and last day of month (24 per year)
Plan Priority Select HMO Vivity HMO
Employee Only $0.00 $0.00
Employee + Spouse $359.64 $380.64
Employee + Child(ren) $239.76 $253.76
Employee + Family $629.37 $666.12
8 Employee Benefits
