Medical Plan

Anthem Blue Cross Bronze Plan

You may visit in-network or out-of-network providers, but consider the cost difference before visiting the doctor. Benefit Tip: This plan has the highest deductible. Coinsurance is the same in the Silver and Bronze plans, so consider whether you prefer a higher annual deductible and lower paycheck premiums (Bronze) or a lower annual deductible and higher paycheck premiums (Silver). Bronze PPO Plan Summary of Benefits and Coverage

Anthem Blue Cross Bronze Plan
	In-Network	Out-of-Network
Calendar Year Deductible
Individual	$3,000	$6,000
Family	$6,000***	$11,000***
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
Individual	$6,000	$11,000
Family	$11,000	$33,000
Coinsurance/Copays	You Pay	You Pay
Preventive Care	$0	50%*
Primary Care Physician	30%*	50%*
Specialist	30%*	50%*
Urgent Care	30%*	50%*
Emergency Room	30%*	30%*
Inpatient Hospital	30%*	50%*
Mental Health & Substance Abuse	You Pay	You Pay
Inpatient	30%*	50%*
Outpatient	30%*	50%*
Pharmacy Retail Rx (up to 30-day supply)	You Pay
Preventive	$0
Generic	$10
Preferred Brand	30%: $25 min.*/$50 max.
Specialty - Non PrudentRx	30%: $50 min.*/$100 max.
Specialty - PrudentRx	$0 cost of share to member if enrolled. If not enrolled 30% coinsurance*
Specialty	30%: $75 min.*/$200 max.
Mail Order Rx (up to 90-day supply)	You Pay
Preventive	$0
Generic	$20*
Preferred Brand	30%: $65 min.*/$125 max.
Non-Preferred Brand	30%: $125 min.*/$250 max.
Specialty - Non PrudentRx	30%: $75 min.*/$200 max.
Specialty - PrudentRx	$0 cost of share to member if enrolled. If not enrolled 30% coinsurance*

*Copay/cost share applies after plan deductible is met.
*For coverage types other than Employee Only, the deductible will automatically default to the family deductible.
**If the actual cost of the drug is less than the minimum, you pay the cost of the drug.
***For coverage types other than Employee Only, the deductible will automatically default to the family deductible.