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2016 Benefits Guide
4
Traditional PPO Plan - BUY UP
Anthem Traditional Plan Summary
(PPO-Blue Access Choice 1D)
Type of
Coverage
Employee
Bi-Monthly Cost
Employee
$0
Employee & Spouse
$141.79
Employee & Child(ren)
$122.46
Employee & Family
$264.25
Benefit/Service
In-Network
Out-of-Network
Deductible
$0/$0
$1,000/$3,000
Coinsurance
100%
70%
Out of Pocket Max.
$0/$0
$4,000/$8,000
Inpatient Hospital
100% after Ded.
70% after Ded.
Outpatient Hospital
100% after Ded.
70% after Ded.
Office Visit Copay
(PCP or Specialist)
$20/$40 copay
70% after Ded.
Emergency Room
$200 copay
$200 copay
Urgent Care
$75 copay
70% after ded.
Prescription
Retail
Mail Order
$10/$25/$45/25%
$10/$65/$135/25%
50% with a minimum
of $45
N/A
Lifetime Max Benefit
Unlimited
Unlimited