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MEDICAL & PRESCRIPTION

MEDICAL & PRESCRIPTION

Anthem KeyCare 30 1000

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $1,000 for Individual coverage and $2,000 for Family Coverage when you use in-network providers.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Resources
Anthem KeyCare Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $1,000 / $2,000 $2,000 / $4,000
Coinsurance 20% after deductible 40% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)		 $4,000 / $8,000 $8,000 / $16,000
Office Visit $15 copay 40% after deductible
Specialist Office Visit $25 copay 40% after deductible
Surgical Services 20% after deductible 40% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 20% after deductible 40% after deductible
Urgent Care Centers $25 copay 40% after deductible
Emergency Medical Care 20% after deductible 20% after deductible
In-Patient Hospital Services 20% after deductible 40% after deductible
Out-Patient Hospital Services 20% after deductible 40% after deductible
Prescription Drugs:
Retail (30 day supply) Tier 1 – $10 / Tier 2 – $40 / Tier 3 – $60 / Specialty 20% up to $250 40% coinsurance
(retail and home delivery)
Mail Order (90 day supply) Tier 1 – $25 / Tier 2 – $100 /Tier 3 – $150 40% coinsurance
(retail and home delivery)
Employee Bi-Weekly Costs:
Employee Only $76.52
Employee + 1 $181.03
Employee + 2 or more $145.39

Anthem KeyCare 30 2000

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $2,000 for Employee only coverage and $2,000 per person up to $4,000 for Family Coverage, Employee + Spouse, Employee + Child(ren).

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Resources
UnitedHealthcare – PPO Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $2,000/ $4,000 $4,000 / $8,000
Coinsurance 30% after deductible 50% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)		 $4,500 / $9,000 $9,000 / $18,000
Office Visit $15 copay 50% after deductible
Specialist Office Visit $25 copay 50% after deductible
Surgical Services 30% after deductible 50% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 30% after deductible 50% after deductible
Urgent Care Centers $25 copay 50% after deductible
Emergency Medical Care 30% after deductible 30% after deductible
In-Patient Hospital Services 30% after deductible 50% after deductible
Out-Patient Hospital Services 30% after deductible 50% after deductible
Prescription Drugs:
Retail (30 day supply) Tier 1 – $10 / Tier 2 – $40 /Tier 3 – $60 / Specialty 20% up to $250 50% after deductible
Mail Order (90 day supply) Tier 1 – $25 / Tier 2 – $100 /Tier 3 – $150 50% after deductible
Employee Bi-Weekly Costs:
Employee Only $55.91
Employee + 1 $131.96
Employee + 2 or more $106.24

Anthem HSA 2700

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: You pay all non-preventive care costs, including prescription drugs, up to the annual deductible. The annual deductible is $2,700 for Individual and $5,400 for other levels of coverage when you use in-network providers.

Coinsurance: Once you have met the deductible, you will pay coinsurance for services received. When you use in-network providers, your coinsurance cost will be 20% for individual and 40% for other coverage levels after the deductible.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Resources
Anthem HSA 2700 Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $2,700/ $5,400 $5,400 / $10,800
Coinsurance 20% after deductible 40% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)		 $4,000 / $8,000 $8,000 / $16,000
Office Visit 20% after deductible 40% after deductible
Specialist Office Visit 20% after deductible 40% after deductible
Surgical Services 20% after deductible 40% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 20% after deductible 40% after deductible
Urgent Care Centers 20% after deductible 40% after deductible
Emergency Medical Care 20% after deductible 20% after deductible
In-Patient Hospital Services 20% after deductible 40% after deductible
Out-Patient Hospital Services 20% after deductible 40% after deductible
Prescription Drugs:
Retail (30 day supply) 20% after deductible 20% after deductible
Mail Order (90 day supply) 20% after deductible 20% after deductible
Employee Bi-Weekly Costs:
Employee Only $28.90
Employee + 1 $67.70
Employee + 2 or more $54.92