Page 18 - open_enrollment_benefits_book_NA_2018_v4

Medical Insurance: Cost Comparison

ANTHEM PPO ANTHEM HSA PPO
Anthem Non- Anthem Non-
Network Network Network Network Network
YOUR COST PER PAYCHECK

Just You $76 $37
• You + Spouse/Partner $166 $83
• You + Child(ren) $136 $68
• You + Family $233 $116
HEALTHCARE COSTS

Annual Deductible (Ded)
• Individual $0 $200 $1,500 $3,000
• Family $0 $600 $3,000 $6,000
Co-insurance 10% 30% 0% 30%

Physician Office Visit $10 Ded, 30% Ded, 0% Ded, 30%

Lab and X-Ray
• Routine 10% Ded, 30% Ded, 0% Ded, 30%
• Complex 10% Ded, 30% Ded, 0% Ded, 30%

Out-of-Pocket Maximum Includes Ded Includes Ded Includes Ded
• Individual $500 $1,500 $3,000 $6,000
• Family $1,000 $3,000 $6,000 $12,000
Hospitalization
• Inpatient 10% Ded, 30% Ded, 0% Ded, 30%
• Outpatient Surgery 10% Ded, 30% Ded, 0% Ded, 30%

Emergency Services $100, 10% $100, Ded, 10% Ded, 0% Ded, 0%

Urgent Care $10 Ded, 30% Ded, 0% Ded, 30%
Wellness Exams No Charge Ded, 30% No Charge Ded, 30%

Hearing Aids 20% Ded, 20% Ded, 20% Ded, 20%
(Medically Necessary)

Chiropractic $10 Ded, 30% Ded, 0% Ded, 30%
(30 Visit Max) (30 Visit Max)

Mental Health &
Substance Abuse
• Inpatient 10% Ded, 30% Ded, 0% Ded, 30%
• Outpatient $10 Ded, 30% Ded, 0% Ded, 30%

PHARMACY COSTS
Retail Pharmacy
(30-Day Supply) Ded, Plus Ded, Plus
• Tier 1 $5 $5 + 50% $10 30%
• Tier 2 $10 $10 + 50% $30 30%
• Tier 3 $10 $10 + 50% $50 30%

Mail Order
(90-Day Supply) Ded, Plus
• Tier 1 $5 Not Covered $10 Not Covered
• Tier 2 $20 Not Covered $60 Not Covered
• Tier 3 $20 Not Covered $100 Not Covered

14