Medical Plan

Anthem Blue Cross Silver Plan

Enjoy the freedom to visit either in-network or out-of-network providers, but keep in mind that your costs may be higher with out-of-network providers. Benefit Tip: This plan features a mid-range annual deductible and premiums from your paycheck – plus includes free money from the Company for your Health Savings Account. Silver PPO Plan Summary of Benefits and Coverage

Anthem Blue Cross Silver Plan
	In-Network	Out-of-Network
Calendar Year Deductible
Individual	$2,000	$4,000
Family	$4,000***	$8,000***
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	20%*	50%*
Specialist	20%*	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	20%*	50%*
Pharmacy Retail Rx (up to 30-day supply)	You Pay
Preventive	$0
Generic	$10
Preferred Brand	20%: $25 min.*/$50 max.
Specialty - Non PrudentRx	20%: $50 min.*/$100 max.
Specialty - PrudentRx	$0 cost of share to member if enrolled. If not enrolled 30% coinsurance*
Specialty	20%: $75 min.*/$200 max.
Mail Order Rx (up to 90-day supply)	You Pay
Preventive	$0
Generic	$20*
Preferred Brand	20%: $65 min.*/$125 max.
Non-Preferred Brand	20%: $125 min.*/$250 max.
Specialty - Non PrudentRx	20%: $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.