Medical and Pharmacy Coverage
The Gardens at Calvary offers the following Medical plans through Anthem and offers “in and out-of-network” benefits.
Insurance Carrier:
Anthem Medical Insurance
Medical Plan:
$2,500 / 70% Copay Plan $5,000 / 70% Copay Plan
$2,500 / 80% Copay Plan
In-Network: Office Visit Copay - Primary Care
$30
$30
$25
Office Visit Copay - Specialist Care
$60
$60
$50
Urgent Care Copay
$60
$60
$60
Emergency Room Care
$250 Copay; then 30% Coinsurance
$250 Copay; then 30% Coinsurance
$250 Copay; then 20% Coinsurance
Preventative Visit Copay
$0
$0
$0
Diagnostic Testing & Blood Work
Deductible; then 30% Coinsurance
Deductible; then 30% Coinsurance
$25
Imaging
Deductible; then 30% Coinsurance
Deductible; then 30% Coinsurance
20% Coinsurance
Coinsurance
70%
70%
20%
Employee Deductible
$2,500
$5,000
$2,500
Family Deductible
$7,500
$15,000
$7,500
Employee Out-of-Pocket Max
$7,500 (includes deductible)
$10,000 (includes deductible)
$7,500 (includes deductible)
Family Out-of-Pocket Max
$22,500 (includes deductible)
$30,000 (includes deductible)
$22,500 (includes deductible)
Inpatient Hospital
Deductible; then 30% Coinsurance
Deductible; then 30% Coinsurance
20% Coinsurance
Outpatient Hospital or Facility
Deductible; then 30% Coinsurance
Deductible; then 30% Coinsurance
20% Coinsurance
Out-of-Network: Coinsurance
60%
60%
40%
Employee Deductible
$5,000
$10,000
$5,000
Family Deductible
$15,000
$30,000
$15,000
Employee Out-of-Pocket Max
$15,000
$20,000
$15,000
Family Out-of-Pocket Max
$45,000
$60,000
$45,000
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$15 Copay
$15 Copay
$15
Tier 2 - Preferred
Not Covered
Not Covered
$35
Tier 3 - Non-Preferred
Not Covered
Not Covered
$60
Tier 4 - Specialty
Not Covered
Not Covered
20% Coinsurance up to $200
Employee Semi-Monthly Deduction Employee Only
$117.34
$92.64
$217.96
Employee + Spouse
$424.72
$372.85
$636.04
Employee + Child(ren)
$382.81
$334.64
$579.03
Family
$690.19
$614.85
$997.10
6 THE GARDENS AT CALVARY 2023 BENEFITS GUIDE
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