
Medical Plan
Anthem Blue Cross Gold Plan
Although services are covered both in-network and out-of-network, your benefits are greater when you choose in-network providers. Benefit Tip: This plan features the lowest annual deductible of the Anthem Blue Cross plans in exchange for a higher premium from your paycheck.
Anthem Blue Cross Gold Plan | |||
---|---|---|---|
In-Network | Out-of-Network | ||
Calendar Year Deductible | |||
Individual | $250 | $250 | |
Family | $750 | $750 | |
Calendar Year Out-of-Pocket Maximum (Includes Deductible) | |||
Individual | $5,000 | $10,000 | |
Family | $10,000 | $30,000 | |
Coinsurance | You Pay | You Pay | |
Preventive Care | $0 | 50%* | |
Primary Care Physician | $25 | 50%* | |
Specialist | $45 | 50%* | |
Urgent Care | 20%* | 50%* | |
Emergency Room | 20%* | 20%* | |
Inpatient Hospital | 20%* | 50%* | |
Mental Health & Substance Abuse | You Pay | You Pay | |
Inpatient | 20%* | 50%* | |
Outpatient | $25 | $25 | |
Pharmacy Retail RX (up to 30-day supply) | You Pay | ||
Preventive | N/A | ||
Generic | $10 | ||
Preferred Brand | $30 | ||
Non-Preferred Brand | $50 | ||
Specialty | $50 | ||
CVS Mail Order RX (up to 90-day supply) | You Pay | ||
Preventive | N/A | ||
Generic | $20 | ||
Preferred Brand | $60 | ||
Non-Preferred Brand | $100 | ||
Specialty (30-day supply only) | $50 |
*After deductible
**If the actual cost of the drug is less than the minimum, you pay the cost of the drug.

Medical Plan
Anthem Blue Cross Gold Plan
Although services are covered both in-network and out-of-network, your benefits are greater when you choose in-network providers. Benefit Tip: This plan features the lowest annual deductible of the Anthem Blue Cross plans in exchange for a higher premium from your paycheck.
Anthem Blue Cross Gold Plan | |||
---|---|---|---|
In-Network | Out-of-Network | ||
Calendar Year Deductible | |||
Individual | $250 | $250 | |
Family | $750 | $750 | |
Calendar Year Out-of-Pocket Maximum (Includes Deductible) | |||
Individual | $5,000 | $10,000 | |
Family | $10,000 | $30,000 | |
Coinsurance | You Pay | You Pay | |
Preventive Care | $0 | 50%* | |
Primary Care Physician | $25 | 50%* | |
Specialist | $45 | 50%* | |
Urgent Care | 20%* | 50%* | |
Emergency Room | 20%* | 20%* | |
Inpatient Hospital | 20%* | 50%* | |
Mental Health & Substance Abuse | You Pay | You Pay | |
Inpatient | 20%* | 50%* | |
Outpatient | $25 | $25 | |
Pharmacy Retail RX (up to 30-day supply) | You Pay | ||
Preventive | N/A | ||
Generic | $10 | ||
Preferred Brand | $30 | ||
Non-Preferred Brand | $50 | ||
Specialty | $50 | ||
CVS Mail Order RX (up to 90-day supply) | You Pay | ||
Preventive | N/A | ||
Generic | $20 | ||
Preferred Brand | $60 | ||
Non-Preferred Brand | $100 | ||
Specialty (30-day supply only) | $50 |
*After deductible
**If the actual cost of the drug is less than the minimum, you pay the cost of the drug.
Sydney Health App
Manage your benefits, claims, and more with the Anthem Blue Cross Sydney Health App. Download from the App Store or Google Play.
Part-time and Temporary employees are eligible for a limited subset of benefits. Union employees: refer to your collective bargaining agreement for your benefits eligibility.