Enrollment Information

Medical Coverage

The following chart summarizes the benefits for the medical plans offered to all eligible employees. 

Anthem Blue Cross
Base Plan
PPO $6,350 Deductible

Anthem Blue Cross
Buy-up Plan
PPO $0 Deductible
In-NetworkOut-of-NetworkIn-NetworkOut-of-Network
Annual Deductible
(Calendar Year)
Individual/Family
$6,350/Individual
$12,700/Family
$6,350/Individual
None
None
Out-of-Pocket Max
(Calendar Year)
Individual/Family
$6,350/Individual
$12,700/Family
$12,700/Individual
$3,000/Individual
$6,000/Family
$10,000/Individual
Member
Co-Insurance
0%
40%
20%
40%
Physician Services
Primary Care
$20 Copay for first 10 visits**, visits 11+ are subject to deductible*
40% after deductible
$25 Copay
$50 Copay
Specialist Visits
$20 Copay for first 10 visits**, visits 11+ are subject to deductible*
40% after deductible
$25 Copay
$50 Copay
Preventive Care
No Copay**
40% after deductible
No Copay
Not Covered
Hospital Services
Hospitalization
$0 after deductible
40% after deductible
20%
40%
Outpatient Surgery
$0 after deductible
40% after deductible
20%
40%
Diagnostic X-Ray & Lab
X-Ray/Lab
Lab: $20 Copay**
X-rays: $0 after ded.
40% after deductible
20%
40%
Emergency and Urgent Care Visits
Emergency Room
$0 after deductible
$250 Copay + 20%
Urgent Care
$20 Copay for first 10 visits**, visits 11+ are subject to deductible*
40% after deductible
$25 Copay
$50 Copay
Prescriptions (90 Day Supply)
Deductible
None
N/A
None
N/A
Generic
$20 Copay
Not Covered
$15 Copay
Not Covered
Brand Formulary
$40 Copay
Not Covered
$40 Copay
Not Covered
Brand Non-Formulary
50%
Not Covered
$60 Copay
Not Covered

*Combination of 10 visits max per calendar year between Primary Care Physician, Specialist, and Urgent Care. Any additional office visits are subject to the deductible.

**Deductible does not apply to the services where the “**” is notated.

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