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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.

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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.