Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Anthem PPO
Plan Information
Plan Name: Anthem PPO
Policy Number: L03990M001
Effective Date: 01/01/2025
Network: Anthem
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
No charge
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
$30 copay
Emergency Room
$150 copay + You pay 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a: $5 copay; Tier 1b: $15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance up to $250 per prescription after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Tier 1a: $10 copay; Tier 1b: $30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$125 copay
Specialty
30% coinsurance up to $250 per prescription after deductible
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
No charge
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 copay + You pay 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance up to $250 per prescription
Preferred Brand
50% coinsurance up to $250 per prescription
Non-Preferred Brand
50% coinsurance up to $250 per prescription
Specialty
50% coinsurance up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Not covered
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
$30 copay
Emergency Room
$150 copay + 20% after deductible
(copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a: $5 copay; Tier 1b: $15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance up to $250 per prescription after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Tier 1a: $10 copay; Tier 1b: $30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$125 copay
Specialty
30% coinsurance up to $250 per prescription after deductible
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
40% after deductible
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 copay + 20% after deductible
(copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance up to $250 per prescription
Preferred Brand
50% coinsurance up to $250 per prescription
Non-Preferred Brand
50% coinsurance up to $250 per prescription
Specialty
50% coinsurance up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Not covered
Plan Documents
Year Carrier Document Name
Contact Information
Anthem HDHP HSA
Plan Information
Plan Name: Anthem HDHP (HSA)
Policy Number: L03990M010
Effective Date: 01/01/2025
Network: Anthem
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,200/$6,400
Out-of-Pocket Max (Individual/Family)
$5,500/$11,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
20% after deductible
Specialist Visit
20% after deductible
Urgent Care
20% after deductible
Emergency Room
20% after deductible
Retail Rx(Up to 30-Day Supply)
Generic
Tier 1a: $5 copay after deductible; Tier 1b: $15 copay after deductible
Preferred Brand
$40 copay after deductible
Non-Preferred Brand
$60 copay after deductible
Specialty
30% coinsurance up to $250 per prescription after deductible
Mail-Order Rx (Up to 100-Day Supply)
Generic
Tier 1a: $10 copay after deductible; Tier 1b: $30 copay after deductible
Preferred Brand
$100 copay after deductible
Non-Preferred Brand
$150 copay after deductible
Specialty
30% coinsurance up to $250 per prescription after deductible
Out-of-Network
Deductible (Individual/Family)
$9,600/$19,200
Out-of-Pocket Max (Individual/Family)
$16,500/$33,000
Preventive Care
40% after deductible
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
40% after deductible
Preferred Brand
40% after deductible
Non-Preferred Brand
40% after deductible
Specialty
40% after deductible
Mail-Order Rx(Up to 90-Day Supply)
Not covered
Plan Documents
Year Carrier Document Name
Contact Information
Kaiser DHMO
Plan Information
Plan Name: Kaiser DHMO
Policy Number: 602059
Effective Date: 01/01/2025
Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay per visit
Emergency Room
10% after deductible (If admitted, inpatient cost share applies.)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
N/A
Specialty
20% coinsurance (not to exceed $250)
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
N/A
Specialty
Not covered
Plan Documents
Year Carrier Document Name
Contact Information
Kaiser HMO HSA
Plan Information
Plan Name: Kaiser HMO HSA
Policy Number: 602059
Effective Date: 01/01/2025
Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,200/$6,400
Out-of-Pocket Max (Individual/Family)
$3,200/$6,400
Preventive Care
$0 (deductible waived)
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
N/A
Specialty
$0 after deductible
Mail-Order Rx (Up to 100-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
N/A
Specialty
Not covered
Plan Documents
Year Carrier Document Name