MEDICAL BENEFITS – Gold Plan
Buy Up Plan Anthem Blue Cross and Blue Shield Gold PPO 2000/20%/5000
Network Services
Non-Network $5,000 single $10,000 family
Calendar Year Deductible
$2,000 single $4,000 family
Annual Out-of-Pocket Maximum
$5,000 single $10,000 / family
$12,500 single $25,000 family
Physician Services Office Visits
$20
50% after deductible
Specialist Visits
$50
50% after deductible
Urgent Care
$50
50% after deductible
Adult Preventive Services
Covered 100% - no copay
No coverage
Well Child Care Exam
Covered 100% - no copay
No coverage
Outpatient Services Outpatient Surgery (Surgery Center/Hospital)
20% after deductible
50% after deductible
Diagnostic Lab / X-Ray
20% after deductible
50% after deductible
MRI, CT Scan and PET (office)
20% after deductible
50% after deductible
Hospital Services Inpatient Hospitalization
20% after deductible
50% after deductible
Emergency Room (Copay waived if admitted)
$500 + 20% (deductible waived)
$500 + 20% (deductible waived)
Prescription Drugs Rx Deductible
-
Retail Pharmacy Generic Brand Formulary
$10 $40 $80
50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
Brand Non-Formulary
Specialty
25%; max charge $500
Number of Day Supply
30 days
-
Mental or Nervous Disorders & Substance Abuse Inpatient
20% after deductible
50% after deductible
Outpatient
$20
50% after deductible
4
Powered by FlippingBook