MEDICAL Y O U R J O U R N E Y T O HEALTH Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hoverovertheinsurancetermsbelowtolearnwhattheymean! Anthem Classic PPO 500/30/50/20 Anthem EPO 3000/25/50/20 DEDUCTIBLE Individual: $500 Individual: $3,000 Family: $1,500 Family: $6,000 Primary Care: $30 copay Primary Care: $25 copay OFFICE VISITS Specialist: $50 copay Specialist: $50 copay REVIEW Urgent Care: $30 copay Urgent Care: $25 copay Inpatient: *20% Coinsurance Inpatient: *20% Coinsurance PLAN SBC’S PROCEDURES Outpatient: *20% Coinsurance Outpatient: *20% Coinsurance Emergency Room: $150 copay Emergency Room: $150 copay then *20% coinsurance then *20% coinsurance Tier 1A: $5 (retail) / $10 (home delivery) Tier 1A: $5 (retail) / $10 (home delivery) Tier 1B: $15 (retail) / $30 (home delivery) Tier 1B: $20 (retail) / $40 (home delivery) PRESCRIPTIONS Tier 2: $30 (retail) / $75 (home delivery) Tier 2: $40 (retail) / $100 (home delivery) Tier 3: $50 (retail) / $125 (home delivery) Tier 3: $60 (retail) / $150 (home delivery) Tier 4: 30% coinsurance up to $250* Tier 4: 30% coinsurance up to $250* OUT-OF-POCKET Individual: $4,000 Individual: $7,350 MAXIMUM Family: $8,000 Family: $14,700 *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits and Coverage for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.