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. Gold PPO Plan Summary of Benefits and Coverage
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/Copays | 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 | ||
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 | ||
*Copay/cost share applies after plan deductible is met.
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. Gold PPO Plan Summary of Benefits and Coverage
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/Copays | 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 | ||
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 | ||
*Copay/cost share applies after plan deductible is met.
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.