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MEDICAL – ANTHEM

MEDICAL – ANTHEM

Coverage to Build a Foundation of Good Health

At Tyto Athene, we understand the importance of good health as the foundation for a productive life at home and at work. That is why we offer medical and prescription coverage, administered through Anthem, to fit your needs and budget.

Keep in mind that you have the flexibility to select the provider or facility of your choice. If you choose an in-network provider, your Anthem benefits will be paid at the highest level.

Anthem KeyCare 30 1000

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $1,000 for Individual coverage and $2,000 for Family Coverage when you use in-network providers.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Anthem KeyCare Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $1,000 / $2,000 $2,000 / $4,000
Coinsurance 20% after deductible 40% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)
$4,000 / $8,000 $8,000 / $16,000
Office Visit $25 copay 40% after deductible
Specialist Office Visit $50 copay 40% after deductible
Surgical Services 20% after deductible 40% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 20% after deductible 40% after deductible
Urgent Care Centers $25 copay 40% after deductible
Emergency Medical Care 20% after deductible 20% after deductible
In-Patient Hospital Services 20% after deductible 40% after deductible
Out-Patient Hospital Services 20% after deductible 40% after deductible
Prescription Drugs:
Retail (30 day supply) Tier 1 – $15 | Tier 2 – $50 | Tier 3 – $85 | Specialty 20% up to $300 40% coinsurance
(Retail and Home Delivery)
Mail Order (90 day supply) Tier 1 – $38 | Tier 2 – $125 | Tier 3 – $213 40% coinsurance
(Retail and Home Delivery)

Anthem KeyCare 30 2000

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $2,000 for Employee only coverage and $2,000 per person up to $4,000 for Family Coverage, Employee + Spouse, Employee + Child(ren).

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Anthem – PPO Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $2,000/ $4,000 $4,000 / $8,000
Coinsurance 30% after deductible 50% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)
$4,500 / $9,000 $9,000 / $18,000
Office Visit $30 copay 50% after deductible
Specialist Office Visit $60 copay 50% after deductible
Surgical Services 30% after deductible 50% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 30% after deductible 50% after deductible
Urgent Care Centers $25 copay 50% after deductible
Emergency Medical Care 30% after deductible 30% after deductible
In-Patient Hospital Services 30% after deductible 50% after deductible
Out-Patient Hospital Services 30% after deductible 50% after deductible
Prescription Drugs:
Retail (30 day supply) Tier 1 – $15 | Tier 2 – $50 | Tier 3 – $85 | Specialty 20% up to $300 50% coinsurance
(Retail and Home Delivery)
Mail Order (90 day supply) Tier 1 – $38 | Tier 2 – $125 | Tier 3 – $213 50% coinsurance
(Retail and Home Delivery)

Anthem HSA 3200

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: You pay all non-preventive care costs, including prescription drugs, up to the annual  deductible. The annual deductible is $3,200 for Individual and $6,400 for other levels of coverage when you  use in-network providers.

Coinsurance: Once you have met the deductible, you will pay coinsurance for services received. When you use in-network providers, your coinsurance cost will be 20% for individual and 40% for other coverage levels after the deductible.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

Anthem HSA 3200 Network Providers Non-Network Providers
Calendar Year Deductible: Single/Family $3,200/ $6,400 $5,400 / $10,800
Coinsurance 20% after deductible 40% after deductible
Maximum Out of Pocket Limit: Single / Family
(Includes the deductible)
$4,500 / $9,000 $8,000 / $16,000
Office Visit 20% after deductible 40% after deductible
Specialist Office Visit 20% after deductible 40% after deductible
Surgical Services 20% after deductible 40% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA 20% after deductible 40% after deductible
Urgent Care Centers 20% after deductible 40% after deductible
Emergency Medical Care 20% after deductible 20% after deductible
In-Patient Hospital Services 20% after deductible 40% after deductible
Out-Patient Hospital Services 20% after deductible 40% after deductible
Prescription Drugs:
Retail (30 day supply) Tier 1- $15 / Tier 2 – $50 / Tier 3 – $85 / Specialty – 20% up to $300 after deductible 40% after deductible
Mail Order (90 day supply) Tier 1- $38 / Tier 2 – $125 / Tier 3 – $213 after deductible 40% after deductible