Medical & Prescription
We offer you a comprehensive benefits program to help you and your family protect your health and financial security. Your benefits are a valuable part of your compensation; we encourage you to learn how your plans work so you can get the most from them. You have two (2) plan options through Anthem.
Watch this video to learn about the difference between HDHPs and PPOs
Medical Highlights (In-Network)
HSA PLAN (HDHP)
Network
Anthem
Type of Deductible
Embedded
Calendar Year Deductible (Individual / Family)1,2
$3,500 / $7,000
Your Coinsurance3
0%
Out-of-Pocket Maximum (Individual / Family)
$4,500 / $9,000
Physician Visit (Primary / Specialist)4
Deductible, then $30 / $60 copay
Preventive Care Services
Covered 100%
Emergency Room Visit
Deductible, then $350 copay
Urgent Care Visit
Deductible, then $75 copay
PPO
Network
Anthem
Type of Deductible
Embedded
Calendar Year Deductible (Individual / Family)
$2,500 / $5,000
Your Coinsurance
20%
Out-of-Pocket Maximum (Individual / Family)
$6,000 / $12,000
Physician Visit (Primary / Specialist)
$30 / $60 copay
Preventive Care Services
Covered 100%
Emergency Room Visit
$350 copay, then 20% coinsurance
Urgent Care Visit
$75 copay
Out-of-Network
Calendar Year Deductible (Individual / Family)
$10,500 / $21,000
Your Coinsurance
50%
Out-of-Pocket Maximum (Individual / Family)
$13,500 / $27,000
Out-of-Network
Calendar Year Deductible (Individual / Family)
$7,500 / $15,000
Your Coinsurance
50%
Out-of-Pocket Maximum (Individual / Family)
$18,000 / $36,000
1. When enrolling in a High Deductible Health Plan, all covered services are subject to the deductible except Preventive Care services.
2. Deductible year runs on the plan year.
3. Coinsurance kicks in once the calendar year deductible is met.
4. Preventive care services include but are not limited to routine wellness exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic eye exam, routine vision and hearing exams. Covers preventive care services rendered in a physician's office and outpatient service centers.
Both medical plans are embedded. An embedded deductible means that each person covered on the plan (employee, spouse, child) has a personal deductible. When each personal deductible is met, coverage begins for that individual only.
Features of High Deductible Health Plan (HDHP) or HSA Plan
A health plan that has lower premiums and higher deductibles than traditional health plans. Only those enrolled in an HDHP are eligible to open and add tax-free money to a health savings account (HSA).
- No up-front copays for medical services (office visits, ER, etc.)
- All services track toward the calendar year deductible and out-of-pocket maximum except for in-network preventive services
- Preventive care services in-network covered at 100%, no annual maximum
- You ARE eligible to enroll in a Health Savings Account
Features of Preferred Provider Organization (PPO)
A health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
- Traditional health plan
- Copays apply to office visits and prescription drug costs
- Preventive care services in-network covered at 100%, no annual maximum
- You are NOT eligible to enroll in a Health Savings Account
- You ARE eligible to enroll in a Flexible Spending Account
Contact the provider of these benefits by calling this phone number or visiting this website: Anthem Customer Service:
(800) 295-4119 | www.anthem.com
WHAT IS A...
Deductible: Amount you have to pay for a covered medical expense before your coinsurance kicks in.
Coinsurance: A percentage of the claim amount you pay (after your deductible is met), while your insurance plan pays for the rest. For example: You pay 20% and the plan pays 80%.
Copay: Fixed fee you may need to pay for healthcare services (i.e., office visits, prescriptions).
Out-of-Pocket Maximum: You will not have to pay more than this amount during your plan year – once you reach it, your insurance plan will cover all additional expenses.
Rx Highlights (CarelonRx)
HDHP
Retail Pharmacy (30 day supply)
Tier 1 - Generic
Level 1: Deductible, then $15 copay Level 2: Deductible, then $25 copay
Tier 2 - Brand Name Formulary
Level 1: Deductible, then $60 copay Level 2: Deductible, then $75 copay
Tier 3 - Brand Name Non-Formulary
Level 1: Deductible, then $125 copay Level 2: Deductible, then $145 copay
Tier 4 - Specialty Medication (Preferred)
Level 1: Deductible, then $400 copay Level 2: Deductible, then $500 copay
Mail-Order Pharmacy (90 day supply)
Tier 1 - Generic
Deductible, then $30 copay
Tier 2 - Brand Name Formulary
Deductible, then $150 copay
Tier 3 - Brand Name Non-Formulary
Deductible, then $313 copay
Tier 4 - Specialty Medication (Preferred)
Deductible, then $400 copay
PPO
Retail Pharmacy (30 day supply)
Tier 1 - Generic
Level 1: $15 copay Level 2: $25 copay
Tier 2 - Brand Name Formulary
Level 1: $60 copay Level 2: $75 copay
Tier 3 - Brand Name Non-Formulary
Level 1: $125 copay Level 2: $145 copay
Tier 4 - Specialty Medication (Preferred)
Level 1: $400 copay Level 2: $500 copay
Mail-Order Pharmacy (90 day supply)
Tier 1 - Generic
$30 copay
Tier 2 - Brand Name Formulary
$150 copay
Tier 3 - Brand Name Non-Formulary
$313 copay
Tier 4 - Specialty Medication (Preferred)
$400 copay
1. You will be responsible for the copay amount until your total expenses have reached the out-of-pocket maximum.
2. Specialty medications are limited to a 30-day supply, regardless of whether they are retail or mail order.
TIERED PHARMACY NETWORK
Level 1 Pharmacies: CVS, Target, Walmart, etc.
Level 2 Pharmacies: Walgreens, Rite Aid, Schnucks, Sam’s Club, Meijer, etc.
Contact the provider of these benefits by calling this phone number or visiting this website: CarelonRx Customer Service:
(833) 419-0530 | carelonrxhelp@carelon.com| www.carelonrx.com
MEDICAL & Rx COSTS
(Based on 24 pays per year)
Employee Only
HDHP: $66.48
PPO: $136.20
Employee + Spouse
HDHP: $152.90
PPO: $330.03
Employee + Children
HDHP: $131.06
PPO: $282.88
Employee + Family
HDHP: $211.15
PPO: $455.76
Note: $25 per pay surcharge for spousal coverage if he or she is offered medical coverage elsewhere
QUESTIONS? CONTACT THE CARE LINE
Care Line is an NFP-sponsored program that is staffed by dedicated professionals to help you understand the benefit options made available to you. Whether you have concerns about a recent claim or bill, finding an in-network doctor or just some guidance on which medical plan is right for you and your family, the Care Line can help educate and advocate. The Care Line is available to all employees and children over 18 who are enrolled on the benefit plan.
Contact the Care Line at (844) 717-8777, or you can submit your questions at callthecareline.com.
The Care Line is open Monday - Friday from 8:00 am - 7:00 pm (EST).