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RAFCO Properties/RAFCO Clean
5
Traditional BASE Plan
Anthem Base Plan Summary
(Blue Access Choice 15,AJ)
Benefit/Service
In-Network
Out-of-Network
Deductible
(Individual/family)
$3,000 / $9,000
$6,000 / $18,000
Coinsurance
80%
50%
Out-of-Pocket Max.
(Individual/family)
$6,600 / $13,200
$13,200 / $26,400
Office Visit
$30/50 Co-Pay
50% after Deductible
Virtual Visits
Office Visit Co-Pay
50% after Deductible
Well care Benefits
100%
50% after Deductible
Lab & X-ray
80% after Deductible
50% after Deductible
Major Diagnostics
80% after Deductible
50% after Deductible
Inpatient Hospital
80% after Deductible
50% after Deductible
Outpatient Surgery
80% after Deductible
50% after Deductible
Emergency Room
$250 Co-Pay, then 20%
Urgent Care
$75 Co-Pay
50% After Deductible
Prescription:
Retail
Mail Order
$15 / $45 / $75 / 25% to $200 max
$15 / $112 / $225 / 25% to $200 max
Type of
Coverage
Employee
Bi-Weekly Cost
Employee
$98.43
Employee & Spouse
$277.63
Employee & Child(ren)
$232.83
Employee & Family
$412.03