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Medical Benefits

Anthem Anthem (HSA Compatible)

PPO PPO
Network Non-Network Network Non-Network

Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Deductible (Annual)
 Individual $250 $750 $2,000 $6,000
 Family $750 $2,250 $4,000 $12,000
Coinsurance (Plan Pays) 90% 70% 80% 60%
Office Visit Copay $10 copay 30% after deductible 20% after deductible 40% after deductible

Out-of-Pocket Maximum
 Individual $2,000 $6,000 $3,425 $10,275
 Family $4,000 $12,000 $6,850 $20,550
Hospitalization
 Inpatient 10% after deductible 30% after deductible 20% after deductible 40% after deductible
 Outpatient 10% after deductible 30% after deductible 20% after deductible 40% after deductible
Lab and X-Ray 10% after deductible 30% after deductible 20% after deductible 40% after deductible
Emergency Services $150 copay plus 10% after deductible $150 copay plus 20% after deductible
Urgent Care $10 Copay 30% after deductible 20% after deductible 40% after deductible

Preventive Care No copay 30% after deductible No copay 40% after deductible
Chiropractic & Acupuncture $10 Copay 30% after deductible 20% after deductible 40% after deductible
Max 20 Visits/Year Max 20 Visits/Year

Pharmacy Benefits
Pharmacy Deductible
 Individual N/A N/A Medical Deductible Medical Deductible
 Family N/A N/A Applies Applies

Retail Pharmacy
 Generic Formulary $5/$15 Copay $5/$20 Copay,
 Brand Name Formulary $30 Copay 50% coinsurance $40 Copay 50% coinsurance
 Non-Formulary $50 Copay $30 Copay
 Supply Limit 30 Days 30 Days

Mail Order Pharmacy
 Generic Formulary $12.5/$37.5 Copay $12.5/$50 Copay
 Brand Name Formulary $90 Copay Not covered $120 Copay Not covered
 Non-Formulary $150 Copay $90 Copay
 Supply Limit 90 Days 90 Days

Video – Learn About Medical Plan Terms
Medical plan terms, such as deductibles, copays, coinsurance and out-of-pocket maximums, can sometimes
be confusing. For a quick video that shows how these work, visit http://video.burnhambenefits.com/terms.

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