B enefit E nrollment O verview
L ook inside for information about : Y our insurance plans and benefits
2022 P lan Y ear
Medical and Pharmacy Coverage RAS Medical Solution is proud to offer you a comprehensive benefits overview. We encourage you to take the time to review the enrollment guide prior to enrollment. Keep in mind that the benefits you select during this enrollment will be effective July 1, 2022.
Insurance Carrier: Plan Description:
Anthem Chamber SMART $1500/100%/$3500 Blue Open Access NPOS 60% of Employee Only Premium
Plan Type:
Employer Contribution: In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$30 $70 $75
Urgent Care Copay Emergency Room Care
Deductible; then $350 Copay
Diagnostic Testing & Blood Work
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
Advanced Imaging
Coinsurance Deductible
100%
$1,500 Individual / $3,000 Family $3,500 Individual / $7,000 Family Deductible; then 100% Coinsurance
Out-of-Pocket Max Inpatient Hospital
Outpatient Hospital or Facility
Hospital: Deductible; then 100% Coinsurance / Facility: $350 Copay
Out-of-Network: Deductible
$4,500 Individual / $13,500 Family
Coinsurance
50%
Out-of-Pocket Max
$10,500 Individual / $31,500 Family
Prescription Drugs: ( 30 Day Supply) Rx Deductible
N/A
Tier 1 - Generic Tier 2 - Preferred
$5
$20 $50 $85
Tier 3 - Non-Preferred
Tier 4 - Specialty
Mail Order Drugs (90 day supply) Employee Bi-Weekly Deduction Employee Only
2.5x Tier 1 / 3x Tier 2-4
$85.79 $300.26 $268.09 $482.39
Employee + Spouse Employee + Child(ren)
Family
Plan Description:
Anthem Basic Life w/AD&D
Employer Contribution:
Paid in full by employer
Benefit Amount
$25,000
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ras medical solution benefits overview
Dental and Vision Coverage
Insurance Carrier:
Anthem
Plan Description:
Dental Insurance
Plan Type:
PPO
Employer Contribution:
50% of Employee Only Premium
Calendar Year Deductible
$50 Individual / $150 Family
Calendar Year Maximum
$1,000
Preventive Services
100%
Basic Services
80%
Major Services
50%
Orthodontia (dependent children only)
N/A
Endo/Perio
Major
Percentile
90%
Employee Bi-Weekly Deduction Employee Only
$8.19
Employee + Spouse
$25.24
Employee + Child(ren)
$37.69
Family
$46.22
Insurance Carrier:
Anthem
Plan Description:
Vision Insurance
Employer Contribution:
50% of Employee Only Premium
Vision Exam
$10 Copay
Materials $25 Copay Frequency: Exam / Lenses / Frames / Contact Lenses once every: 12 months / 12 months / 24 months / 12 months Frame Allowance (Retail) $150 Contact Lens Allowance $150 Employee Bi-Weekly Deduction Employee Only $1.38 Employee + Spouse $4.18 Employee + Child(ren) $4.20 Family $7.90
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