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Places for People, Inc.
2016 Annual Enrollment
2016 Page 2
Benefit/Service
PPO Plan
In Network
PPO High Deductible
In Network
H.S.A Plan
In Network
Deductible
Individual:
Family:
$2,350
$4,700
$5,000
$10,000
$3,000
$6,000
Coinsurance
90%
90%
90%
Out-of-Pocket Max.
Individual:
Family:
$6,450
$12,900
$6,450
$12,900
$4,000
$8,000
Office Visit Co-pay
Primary Care:
Specialist:
$25
$50
$30
$60
Deductible /
Coinsurance
Preventive Services
100%
100%
100%
Hospitalizations
Deductible /
Coinsurance
Deductible /
Coinsurance
Deductible /
Coinsurance
Visit Co-pay
Urgent Care:
Emergency Room:
$75
$250
$75
$250, then 10%
Deductible /
Coinsurance
Prescription Co-pay
Tier 1:
Tier 2:
Tier 3:
Mail Order:
$15
$40
$75
$38 / $100 / $188
$15
$40
$75
$38 / $100 / $188
Ded. first, then
$10
$35
$60
$25 / $88 / $150
Below is a summary of the three medical plan options available beginning January 1, 2016. It is to your
advantage to use in network providers. If you go out of network, you will be responsible for any amount
exceeding Anthem’s negotiated discounts plus any deductible and co-insurance associated with your
procedure.
The in network benefits for each plan are illustrated side-by-side below so that you can compare them. There
are out of network benefits associated with each of these options. Please refer to the Anthem Benefit
Summaries for more detailed information.
Remember!!
Regardless of the medical plan option you choose, all copayments for medical and
pharmacy will apply to your out of pocket maximum! This means once you have satisfied your entire
out of pocket maximum responsibility, all other services and prescriptions received in the calendar year
would be covered at 100%!!
SUMMARY OF MATERIAL MODIFICATION—
Your Employer has amended the Places for People, Inc. Health Plan. This contains a
summary of the modifications that were made. It should be read in conjunction with the Summary Plan Description. If you need a copy
of your Summary Plan Description, please contact Human Resources.