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2016-2017 Benefits Guide
6
Traditional BUY UP Plan
Anthem Buy Up Plan Summary
(Blue Access Choice 7,AL)
Benefit/Service
In-Network
Out-of-Network
Deductible
(Individual/family)
$2,000 / $6,000
$4,000 / $12,000
Coinsurance
100%
70%
Out-of-Pocket Max.
(Individual/family)
$4,000 / $8,000
$8,000 / $16,000
Office Visit
$25/50 Co-Pay
70% after Deductible
Virtual Visits
Office Visit Co-Pay
50% after Deductible
Well care Benefits
100%
70% after Deductible
Lab & X-ray/Diagnostics
100%
70% after Deductible
Inpatient Hospital
100% after Deductible
70% after Deductible
Outpatient Surgery
100% after Deductible
70% after Deductible
Emergency Room
$250 Co-Pay
Urgent Care
$75 Co-Pay
70% After Deductible
Prescription:
Retail
Mail Order
At Participating Pharmacies
:
$10 / $35 / $60 / 25% to $200 max
$10 / $90 / $180 / 25% to $200 max
Type of
Coverage
Employee
Bi-Weekly Cost
Employee
$137.74
Employee & Spouse
$356.23
Employee & Child(ren)
$301.61
Employee & Family
$520.11