Copays, Deductible and Coinsurance Amounts

For Active Employees and non-Medicare Retirees Effective July 1, 2018

Please note: There are some exceptions to the tables below; please see the Benefits Summary (MS Word) for a more complete explanation of medical coverage.

Medical Coverage

Type of Visit or Test Copay Amount
Office visit with a primary care doctor who participates in the Anthem network $20
Office visit with a specialist who participates in the Anthem network $40
Visit to a participating walk-in clinic (PDF) $25
Visit to an emergency room (copay is waived if admitted to in-patient status) $300
  • Office visit copay is waived for preventive visits
  • No referral required by the insurance plan for visits to specialist or walk-in clinic
Out-of-Pocket Expense Individual Family
In-Network Out-of-Network In-Network Out-of-Network
Calendar year deductible $600 $3,000 $1,200 $6,000
Coinsurance rate - participating provider 10% 40% 10% 40%
Annual maximum out-of-pocket expense
(deductible + coinsurance + medical copay)
$2,000 $5,000 $4,000 $10,000

Prescription Coverage

Medication Category Up to 30-Day Supply
Copay Amount Per Prescription
Up to 90-Day Supply
Copay Amount Per Prescription
Generics $10 $15
Preferred brand-name $30 $45
Non-preferred brand name $45 $70
Specialty 25% coinsurance up to $150 25% coinsurance up to $225
Lifestyle $50 $75

State of Maine Statute: Title 5 285, 285-A and 286