BUY-UP PLAN
Medical benefits are provided through Anthem Blue Cross Blue Shield. Consider the physician networks, premiums, and out-of-pocket costs for each plan when making a selection.
Plan Details
Network
BCBS
Plan Type
-
HSA Eligible
-
FSA Eligible
Yes
Carrier
Anthem Blue Cross Blue Shield
BUY-UP PLAN Premiums
WEEKLY CONTRIBUTIONS
| Coverage Tier | WELLNESS | NON-WELLNESS |
|---|---|---|
| Employee only | $71.24 | $87.39 |
| Employee + spouse | $180.20 | $212.51 |
| Employee + child(ren) | $148.73 | $164.88 |
| Employee + family | $264.49 | $296.79 |
Employee only
- WELLNESS
- $71.24
- NON-WELLNESS
- $87.39
Employee + spouse
- WELLNESS
- $180.20
- NON-WELLNESS
- $212.51
Employee + child(ren)
- WELLNESS
- $148.73
- NON-WELLNESS
- $164.88
Employee + family
- WELLNESS
- $264.49
- NON-WELLNESS
- $296.79
Medical Services
| Service | IN-NETWORK |
|---|---|
| Annual deductible - individual | $1,000 |
| Annual deductible - family | $3,000 |
| Coinsurance (employee pays) | 20%* |
| Annual out-of-pocket maximum (maximum includes deductible) - individual | $4,500 |
| Annual out-of-pocket maximum (maximum includes deductible) - family | $9,000 |
| Preventive care | Covered 100% |
| Primary care | $25 copay |
| Specialist services | $50 copay |
| Mental health -: inpatient | 20% coinsurance |
| Mental health -: outpatient | 20% coinsurance |
| Urgent care | $75 copay |
| Emergency room | $250 copay |
Annual deductible - individual
- IN-NETWORK
- $1,000
Annual deductible - family
- IN-NETWORK
- $3,000
Coinsurance (employee pays)
- IN-NETWORK
- 20%*
Annual out-of-pocket maximum (maximum includes deductible) - individual
- IN-NETWORK
- $4,500
Annual out-of-pocket maximum (maximum includes deductible) - family
- IN-NETWORK
- $9,000
Preventive care
- IN-NETWORK
- Covered 100%
Primary care
- IN-NETWORK
- $25 copay
Specialist services
- IN-NETWORK
- $50 copay
Mental health -: inpatient
- IN-NETWORK
- 20% coinsurance
Mental health -: outpatient
- IN-NETWORK
- 20% coinsurance
Urgent care
- IN-NETWORK
- $75 copay
Emergency room
- IN-NETWORK
- $250 copay
- *After deductible
RETAIL RX (30-DAY SUPPLY)
| IN-NETWORK | |
|---|---|
| Generic | $10 copay |
| Preferred | $30 copay |
| Non-preferred | $60 copay |
Generic
- IN-NETWORK
- $10 copay
Preferred
- IN-NETWORK
- $30 copay
Non-preferred
- IN-NETWORK
- $60 copay
- *After deductible
MAIL ORDER RX (90-DAY SUPPLY)
| IN-NETWORK | |
|---|---|
| Generic | $25 copay |
| Preferred | $75 copay |
| Non-preferred | $150 copay |
Generic
- IN-NETWORK
- $25 copay
Preferred
- IN-NETWORK
- $75 copay
Non-preferred
- IN-NETWORK
- $150 copay
- *After deductible
Plan Notes
- If you have several covered dependents, all charges used to apply toward a “per individual” deductible amount will also be applied toward the “per family” deductible amount.
- When the family deductible amount is reached, no further individual deductibles will have to be met for the remainder of that plan year.
- No member may contribute more than the individual deductible amount to the “per family” deductible amount.