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Medical

1. Select Dependents

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Justin

Chloe

Shawn

2. Choose a plan

Selected Plans:

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@[[sp.name]]

$@[[sp.employee_cost]] per pay

@[[p.name]]

@[[p.carrier]]

Effective Start Date:

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Your cost: $@[[p.employee_cost]]

Your per pay cost

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@[[p.name]]

@[[p.carrier]]

Effective Start Date:

@[[p.date]]

Your cost: $@[[p.employee_cost]]

Your per pay cost

$@[[p.employer_cost]]

Company’s per pay cost

Enrollment in this plan is required by your employer.

Plan Details

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I want to waive Medical coverage

Your Elected Benefits

Medical

$50.00

Total Per Pay

$50.00

Plan Description

This is a PPO plan with Anthem. PPO plans provide richer benefits at a higher cost, and also allow subscribers to visit a larger network of doctors and facilities.

Coverage

Covered Services	In-Network	Out-of-Network
Coverage Basic Annual Individual Deductible Annual Family Deductible Individual Out-of-Pocket Max Family Out-of-Pocket Max	$3,000 $6,000 $4,000 $8,000	$6,000 $12,000 $8,000 $16,000
Physician / Medical Services Preventive Services Primary Care Physician Specialist Diagnostic Imaging Prental/Postnatal Care Diagnostic Lab	$0 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible	no coverage 70% after deductible 70% after deductible 70% after deductible 70% after deductible 70% after deductible
Hospital Services Inpatient Hospital Outpatient Hospital Inpatient Facility Outpatient Facility	100% after deductible 100% after deductible 100% after deductible 100% after deductible	70% after deductible 70% after deductible 70% after deductible 70% after deductible
Emergency Care Services Emergency Room Emergency Transportation Urgent Care Ambulance	100% after deductible 100% after deductible 100% after deductible 100% after deductible	100% after deductible 100% after deductible 70% after deductible 70% after deductible
Prescription Drugs Retail Generic Drugs Retail Preferred Brand Drugs Retail Non-Preferred Brand Drugs Retail Specialty Drugs	$10 (after deductible) $40 (after deductible) $40 (after deductible) 20% to $250 max (after deductible)	not covered not covered not covered not covered

Web Link

Find a Doctor

Customer Service

888-777-7777

Plans	Anthem Medical Plan PPO	UnitedHealthcare Medical Plan HDHP

Plans	Anthem Medical Plan PPO KP Silver $ 1000	UnitedHealthcare Medical Plan HDHP UHC HDHP Bronze HSA
Plans	Per Pay Cost	$ 70.50	$ 50.00
Coverage Basics Annual Individual Deductible Annual Family Deductible Coinsurance	$ 1,000 $ 2,000 20%	$ 3,000 $ 6,000 10%
			Physician / Medical Services Preventive Services Primary Care Physician Specialist	$ 0 $ 25 copay $ 45 copay	$ 0 10% after deductible 10% after deductible
						Hospital Services Inpatient Hospital Outpatient Hospital	20% after deductible 20% after deductible	10% after deductible 10% after deductible
									Emergency Care Services Emergency Room Urgent Care	$ 100 copay $ 45 copay	$ 250 copay $ 100 copay
Extended Care Services Home Health Care Hospice Services	20% after deductible 20% after deductible	10% after deductible 10% after deductible
			Additional Services Mental Health/Substance Abuse Inpatient Mental Health/Substance Abuse Outpatient Child Dental Care	$ 20 copay after deductible $ 45 copay 20% after deductible	10% after deductible 10% after deductible 10% after deductible
						Prescription Drugs Prescription Deductible Retail Supply Limit Retail Generic Drugs Retail Preferred Brand Drugs Retail Non-Preferred Brand Drugs	0% 30 days $ 5 copay $ 10 copay $ 20 copay	Included with Medical 30 days $ 20 copay $ 50 copay $ 75 copay

Selected Plans:

Delete Primary Care Physician

I want to waive Medical coverage

Your Elected Benefits