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 $750
Plan Information
Plan Name: Anthem PPO $750
Policy Number: L09899
Effective Date: 01/01/2025
Provider Network: Blue Access PPO
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)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
Preferred PCP (EPHC): $5 copay
All other in-network PCPs: $20 copay
Specialist Visit
$50 copay
Urgent Care
$20 copay (deductible waived)
Emergency Room
$300 copay per visit + 20% coinsurance (deductible waived)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$75 copay
Specialty
25% coinsurance (up to $350 per prescription)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$105 copay
Non-Preferred Brand
$225 copay
Specialty
25% coinsurance (up to $350 per prescription)
Out-of-Network
Deductible (Individual/Family)
$2,250/$4,500
Out-of-Pocket Max (Individual/Family)
$9,000/$18,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$300 copay per visit + 20% coinsurance (deductible waived)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance
Preferred Brand
50% coinsurance
Non-Preferred Brand
50% coinsurance
Specialty
50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Anthem PPO $3,000
Plan Information
Plan Name: Anthem PPO $3000
Policy Number: L09899
Effective Date: 01/01/2025
Provider Network: Blue Access PPO
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)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$7,000/$14,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
Preferred PCP (EPHC): $5 copay
All other in-network PCPs: $20 copay
Specialist Visit
$50 copay
Urgent Care
$20 copay (deductible waived)
Emergency Room
$300 copay + 30% coinsurance (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Preferred Network Pharmacy
Generic
$10 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$75 copay
Specialty
25% coinsurance (up to $350 per prescription)
Mail-Order Rx (Up to 90-Day Supply)
Preferred Network Pharmacy
Generic
$30 copay
Preferred Brand
$105 copay
Non-Preferred Brand
$225 copay
Specialty
25% coinsurance (up to $350 per prescription)
Out-of-Network
Deductible (Individual/Family)
$9,000/$ 18,000
Out-of-Pocket Max (Individual/Family)
$21,000/$42,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$300 copay + 30% coinsurance (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance
Preferred Brand
50% coinsurance
Non-Preferred Brand
50% coinsurance
Specialty
50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered