For Active Employees and non-Medicare Retirees Effective July 1, 2023
Please note: There are some exceptions to the tables below; please see the Benefits Summary for a more complete explanation of health coverage.
Health 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 + health 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 |