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Medical / In-Network Only
This comparison chart shows a brief summary of the medical benefits available.
Anthem Blue Cross
80-E PPO 1 Plan
Anthem Blue Cross
80-G PPO 2 Plan
Mental Health/Substance Abuse
Inpatient
Outpatient
20% of charges
$20 (deductible waived)
20% of charges
$30 (deductible waived)
Prescription Drugs
Deductible on Brand Drugs
$200 Individual/
$500 Family
$200 Individual/$500 Family
Annual Out-of-Pocket Maximum
$2,500 Individual/
$3,500 Family
$2,500 Individual/$3,500 Family
Pharmacy
Retail-30 day supply
Costco Pharmacy
Mail Order
Costco
Pharmacy
(90 day supply)
Navitus
(30 day supply)
$10-Generic/$35-Brand
$0 Generic/$35 Brand (30 day supply)
$0 Generic/$90 Brand (90-day supply)
$0 Generic/ $90 Brand
$35 Specialty
$10- Generic/$35- Brand
$0 Generic/$35 Brand (30-day supply)
$0 Generic/$90 Brand (90-day supply)
$0 Generic / $90 Brand
$35 Specialty
Skilled Nursing
Semi-Private Room (100 days/year)
Plan pays 80% of charges
Plan pays 80% of charges
Pregnancy and Maternity
Office Visit
$20 (deductible waived)
$30 (deductible waived)
Therapy
Physical, Occupational, & Speech
Plan pays 80% of charges
Plan pays 80% of charges
Inpatient or Outpatient Hospice
Play pays 100%
Play pays 100%
Home Health Care
Services and supplies –subject to
utilization review (limited to 100
days/year
Plan pays 80% of charges
Plan pays 80% of charges