ANTHEM PPO GOLD $1000

Policy Info

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Eligibility Options

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Required

Eligibility Rules

Plan Eligibility

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New Hire Waiting Period

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Termination Rule

Required

Newly Eligible Rules

Enable these rules if existing employees who become newly eligible for benefits due to an employment change, such as a change in department, have different waiting period rules. If not enabled, the standard new hire waiting period will apply.

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Rehire Rules

Enable these rules if rehired employees do not have to satisfy the waiting period again, or have different waiting period rules. If not enabled, the standard new hire waiting period will apply.

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Plan Bundling & Dependencies

Contingencies

Enable these rules if employees are required to enroll in another plan in order to be eligible for enrollment in this plan.

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Restrictions

Enable these rules if employees are not eligible for enrollment in this plan if they are enrolled in another plan.

Required
Required

Eligibility Underwriting Questions

Eligibility underwriting questions can be configured to support scenarios where a carrier requires initial field underwriting to determine if an employee and/or spouse meets the minimum necessary requirements to enroll in a plan. Questions will be presented to employees during enrollment, and they will be required to answer the question(s) before making an enrollment selection. Questions must be created at the company level (under the Templates tab) before they can be added to a plan.
Underwriting Questions
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Coverage

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Coverage Basics

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Physician / Medical Services

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Hospital Services

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Emergency Care Services

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Extended Care Services

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Additional Services

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Prescription Drugs

Required
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Rate Options

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Required and must be between 0 and 100
  • @[[getCoverageTierGroupNameByID(tierGroup.id)]]
    • @[[item.name]]
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$
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Monthly Rates

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Monthly Rates

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Monthly Rates

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No rates have been defined!
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Contribution Options

Monthly Contribution

Contribution Schedule #1
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Contribution strategy is required
  • @[[getCoverageTierGroupNameByID(tierGroup.id)]]
    • @[[item.name]]
Coverage tier is required
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Enrollment Options

The PCP fields captured during enrollment are PCP ID, PCP Name and PCP Location

Carrier Forms

Employee demographic and enrollment information will be mapped to forms that are attached to this plan. Employees will be required to view completed forms for accuracy before they can submit their enrollment.
Carrier Forms
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Small Business Enrollment Form
You must input a plan name.
You must provide the Group / Policy Number.

Disclosures

Disclosures can be added to support scenarios where a carrier requires specific communication/text to be disclosed to employees after they make an enrollment selection. Disclosures will be presented to employees during enrollment, and they will be required to acknowledge that they have read the disclosure text before proceeding to the next step.
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Disclosures
Add Disclosure
Disclosure Name Actions Status
Medical Plan A Disclosure
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Delete
Active

Plan Riders

A rider is an insurance policy provision that adds benefits to, or amends the terms of, a basic insurance policy. Riders provide insured parties with options such as additional coverage, or they may even restrict or limit coverage. Note: Rider costs must be entered as the monthly rate.
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Resources

Optional plan resources. Employees can access this information via the plan details. link during enrollment, and throughout the year from their benefits portal.

Website Links
Contacts
Customer Service
888-777-7777
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Documents

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.

Payroll Deduction Codes

Deduction Frequency Overrides

Payroll deduction overrides have been locked because at least one employee has enrolled in this plan and changes could impact existing enrollment records. Please contact support if you need to make changes to this plan.

Optional override settings for benefit deductions to accommodate scenarios where employee pay and deduction frequencies are different. For example, employees are paid bi-weekly (26 pays), but benefit deductions are only taken out of 24 pay dates. Per pay costs will be calculated accordingly.

Summary

0 Enrolled   
2097 Eligible
Medical
Anthem Blue Cross
ANTHEM PPO GOLD $1000
Med Gold 1000
Cf-12345679
PPO
No
gold
12/01/2019
11/30/2020
No
26 years old
26 years old
--
--

Plan Eligibility
New Hire Waiting Period

Waiting Period: 60 Day(s) 1st of month after

Termination Rule

End Coverage: End of Termination Month

Newly Eligible Rules

Waiting Period: 0 Day(s) 1st of month after

Rehire Rules

Waiting Period: 30 Day(s) 1st of month after

Rehire within: 90 Day(s)

 
In Network
Out of Network
Coverage
Annual Individual Deductible
1000
2000
Annual Family Deductible
2000
4000
Coinsurance
80%
80%
Physician/Medical Services
Preventive Services
0%
0%
Primary Care Physician
$25 copay
80%
Specialist
$45 copay
80%
Hospital Services
Inpatient Hospital
20%
60%
Outpatient Hospital
20%
60%
Emergency Services
Emergency Room
$100 copay
$100 copay
Urgent Care
$30 copay
60%
Extended Care Services
Home Health Care
$100 copay
$100 copay
Hospice Services
$30 copay
60%
Additional Services
Prescription Drugs
Prescription Deductible
$0
$0
Retail Supply Limit
60 Days
30 Days
Retail Generic Drugs
$0 copay
80%
Retail Preferred Brand Drugs
$25 copay
80%
Retail Specialty Drugs
$75 copay
80%

Additional Coverage / Notes


Composite
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Standard Composite 2 (+children)
3 child(ren)
$
$
$
$
Yes
By Coverage Tier
Standard Composite 2 (+children)
Company Flat Percentage: 50.00 %
Company Additional Percentage: 25.00 %
Company Additional Percentage: 25.00 %
Company Additional Percentage: 25.00 %
Pre Tax
No
Enrollment Options
Yes
Yes
No

Contacts

Documents

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.