MEDICAL INSURANCE
MEDICAL PLAN INFORMATION
65%+ FTE FACULTY 75%+ FTE STAFF
ELIGIBILITY
PLAN INFORMATION
PPO
HDHP
BLUE ACCESS PPO CARE NETWORK
IN NETWORK
OUT OF NETWORK
IN NETWORK
OUT OF NETWORK
$700 INDIVIDUAL $1,400 FAMILY $1,900 INDIVIDUAL $3,800 FAMILY
$1,400 INDIVIDUAL $2,800 FAMILY $3,800 INDIVIDUAL $7,600 FAMILY
$1,900 INDIVIDUAL $3,800 FAMILY $3,800 INDIVIDUAL $7,600 FAMILY
$3,800 PER PERSON $7,600 FAMILY $7,600 INDIVIDUAL $15,200 FAMILY
ANNUAL DEDUCTIBLE
ANNUAL OUT OF POCKET MAXIMUM
ANNUAL HEALTH SAVINGS ACCOUNT FUNDING (UC)
$325 – $825 EE $650 - $1,650 FAMILY
$325 – $825 EE $650 - $1,650 FAMILY
NOT APPLICABLE
NOT APPLICABLE
65% AFTER DEDUCTIBLE 65% AFTER DEDUCTIBLE
65% AFTER DEDUCTIBLE 65% AFTER DEDUCTIBLE
PREVENTIVE CARE**
COVERED 100%
COVERED 100%
80% AFTER DEDUCTIBLE
80% AFTER DEDUCTIBLE
COVERED SERVICES
PHARMACY
30% CO-INSURANCE
SOURCE SUPPLY QUANTITY
RETAIL ONE MONTH SUPPLY
MAIL ORDER THREE MONTH SUPPLY
80% AFTER DEDUCTIBLE
DRUG TYPE GENERIC FORMULARY NON-FORMULARY SPECIALTY
$60 MAXIMUM $110 MAXIMUM $150 MAXIMUM $250 MAXIMUM
$30 MAXIMUM $55 MAXIMUM $75 MAXIMUM $250 MAXIMUM
EMPLOYEE CONTRIBUTION
RATES VARY BASED ON PLAN SELECTION AND TOTAL ANNUAL BASE PAY (UC + UCP)
ANTHEM
PLAN ADMINISTRATOR
FOR MORE INFORMATION: www.anthem.com
EMPLOYEES HAVE 45 DAYS TO ENROLL VIA UC Flex/ESS IF NO ELECTIONS ARE MADE WITHIN 45 DAYS, EMPLOYEES WILL BE ENROLLED IN THE PPO EMPLOYEE ONLY COVERAGE PLAN
NEXT STEPS
** AS RECOMMENDED BY THE AMERICAN MEDICAL ASSOCIATION
Made with FlippingBook Online newsletter maker