Medical and Pharmacy Coverage
J&L Ventures, LLC offers the following plans through Anthem Blue Cross Blue Shield. Please reference the Summary Plan Description for more details. Insurance Carrier: Anthem Blue Cross Blue Shield Medical Insurance Medical Plan Number: High Copay Plan Low Copay Plan In-Network: Office Visit Copay - Primary Care $25 Copay per visit Deductible; then 30% Coinsurance Office Visit Copay - Specialist Care $50 Copay per visit Deductible; then 30% Coinsurance Urgent Care Copay $60 Copay per visit Deductible; then 30% Coinsurance Emergency Room Care $150 Copay; then 20% Coinsurance $250 Copay; then 30% Coinsurance Preventative Visit Copay $0 $0 Diagnostic Testing & Blood Work $0 $0 Imaging Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Coinsurance 80% 70% Employee Deductible $1,500 $2,500 Family Deductible $4,500 $7,500 Employee Out-of-Pocket Max $7,150 $7,150 Family Out-of-Pocket Max $14,300 $14,300 Inpatient Hospital Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Outpatient Hospital or Facility Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Out-of-Network: Coinsurance 50% 50% Employee Deductible $4,500 $7,500 Family Deductible $13,500 $22,500 Employee Out-of-Pocket Max $21,450 $21,450 Family Out-of-Pocket Max $42,900 $42,900 Prescription Drugs: ( 30 Day Supply) Rx Deductible $300 Individual / $600 Family $1,000 Individual / $2,000 Family Tier 1 - Generic $30 $15 Tier 2 - Preferred Deductible met; then $55 Copay Deductible met; then $50 Copay Tier 3 - Non-Preferred Deductible met; then $90 Copay Deductible met; then 20% Coinsurance Tier 4 - Specialty Pay at appropriate tier Deductible met; then 20% Coinsurance Employee Bi-Weekly Deduction Employee Only $68.00 $53.00 Employee + Spouse $140.00 $110.00 Employee + Child(ren) $130.00 $99.00 Family $218.00 $167.00
5 J&L Ventures, LLC 2022 Enrollment Guide
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