Which Medical Plan is Right?
This year we are proud to offer three medical plan options through Anthem BCBS PPO Network.
The chart below is a brief summary of benefits available to eligible employees. Please refer to the summary plan descriptions for complete plan details.
Medical Plan Comparison
Medical Plan Highlights
| | Anthem 2000 PPO |
Anthem 5000 PPO |
Anthem HSA 6500 PPO |
|||
|---|---|---|---|---|---|---|
| Member Responsibility | In-Network | In-Network | In-Network | |||
| Annual Deductible | ||||||
| Individual | $2,000 | $5,000 | $6,500 | |||
| Family | $4,000 | $10,000 | $13,000 | |||
| Coinsurance | 20% | 0% | 0% | |||
| Maximum Out-of-Pocket | ||||||
| Individual | $5,000 | $8,550 | $6,525 | |||
| Family | $10,000 | $17,100 | $13,050 | |||
| Physician Office Visit | ||||||
| Primary Care | $15 | $25 | 0% AD | |||
| Specialty Care | $30 | $50 | 0% AD | |||
| Preventive Care | ||||||
| Preventive Care | No Charge | |||||
|
Telehealth (Primary Care/MH) |
$15 | $25 | 0% AD | |||
| Diagnostic Services | ||||||
| X-ray and Lab Tests | 20% AD | 30% AD | 0% AD | |||
| Complex Radiology | 20% AD | 30% AD | 0% AD | |||
| Urgent Care Facility | $60 | $100 | 0% AD | |||
| Emergency Room | 20% AD | 30% AD | 0% AD | |||
| Inpatient Facility | 20% AD | 30% AD | 0% AD | |||
| Outpatient Facility & Surgical | 20% AD | 30% AD | 0% AD | |||
| Mental Health & Substance Use | ||||||
| Inpatient | 20% AD | 30% AD | 0% AD | |||
| Outpatient Office Visit | 20% AD | 30% AD | 0% AD | |||
| Retail Pharmacy (30-day supply) | ||||||
| Pharmacy Deductible | $0 Ind./$0 Family | $500 Ind./$1,000 Family | Medical Ded. Applies | |||
| Generic (Tier 1)* | $5 | $5 AD | $15 AD | |||
| Preferred (Tier 2) | $50 | $50 AD | $50 AD | |||
| Non-Preferred (Tier 3) | $100 | $100 AD | $85 AD | |||
| Preferred Specialty (Tier 4) | 20% up to $250 | 20% up to $250 AD | 20% up to $300 AD | |||
| Mail Order Pharmacy (90-day supply) | ||||||
| Generic (Tier 1) | $13 | $13 AD | $38 AD | |||
| Preferred (Tier 2) | $125 | $125 AD | $125 AD | |||
| Non-Preferred (Tier 3) | $250 | $250 AD | $213 AD | |||
| Preferred Specialty (Tier 4)** | 20% up to $250 | 20% up to $250 AD | 20% up to $300 AD | |||
| Member Responsibility | WEEKLY RATES | WEEKLY RATES | WEEKLY RATES | |||
| Employee | $45.17 | $22.88 | $18.63 | |||
| Employee + Spouse | $149.33 | $142.48 | $96.74 | |||
| Employee + Child(ren) | $105.91 | $100.41 | $63.64 | |||
| Employee + Family | $197.48 | $188.99 | $132.30 | |||
| AD = After Deductible | ||||||
| * Deductible is waived for some preventive generics | ||||||
| ** 30 day supply only | ||||||
| Note: Out-of-network benefits available for all plans consist of higher premiums and coinsurance and may be susceptible to balance billing for any charges over the allowable limit for a service. Remaining in-network for services is advised. See SPD for details or anthem.com to see if your provider is in-network. | ||||||
Spousal Surcharge (Effective 1/1/2025)
- If your spouse has health insurance provided to them by their employer and you elect to cover them on your plan here, you will pay a surcharge of $36 per pay.
- This additional charge only applies to medical coverage. You can enroll your spouse in any other plans offered without the additional surcharge.
- You will have to complete an affidavit to enroll your spouse in medical coverage.
Plan Documents
Wellbeing Rewards 200
Sydney Health Mobile App Flier
Summary of Benefits Anthem KeyCare 15 2000
Summary of Benefits Anthem KeyCare 25 5000
Summary of Benefits Anthem HSA 6500
Summary of Benefits and Coverage Anthem KeyCare 15 2000
Summary of Benefits and Coverage Anthem KeyCare 25 5000
Summary of Benefits and Coverage Anthem HSA 6500
Lark Program Digital Health
Lark Program Digital Health - Spanish
Condition Care
