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 Blue Cross HSA 1650
Plan Information
Plan Name: Anthem Blue Cross HSA 1650
Policy Number: L05224
Effective Date: 01/01/2025
Provider Network: Prudent Buyer 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/Member/Family)
$1,650/$3,300/$4,000
Out-of-Pocket Max (Individual/Member/Family)
$4,000/$4,000/$8,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a: $5 copay after deductible
Tier 1b: $15 copay after deductible
Preferred Brand
$40 copay
Non-Preferred Brand
$60 copay
Specialty
30% after deductible, up to $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
Tier 1a: $10 copay
Tier 1b: $30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$150 copay
Specialty
30% after deductible, up to $250
Out-of-Network
Deductible (Individual/Member/Family)
$4,800/$4,800/$9,600
Out-of-Pocket Max (Individual/Member/Family)
$12,000/$12,000/$24,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a: 30% after deductible up to $250
Tier 1b: 30% after deductible up to $250
Preferred Brand
30% coinsurance, up to $250
Non-Preferred Brand
30% coinsurance, up to $250
Specialty
30% after deductible, up to $250
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 Blue Cross Premier PPO 250
Plan Information
Plan Name: Anthem Blue Cross Premier PPO 250
Policy Number: L05224
Effective Date: 01/01/2025
Provider Network: Prudent Buyer 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)
$250/$750
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$15 copay (deductible does not apply)
Specialist Visit
$15 copay (deductible does not apply)
Urgent Care
$15 copay (deductible does not apply)
Emergency Room
$100 + 10% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a (Typically Lower Cost Generic):
$5 copay
Tier 1b (Typically Generic):
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% after deductible, up to $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
Tier 1a (Typically Lower Cost Generic):
$10 copay
Tier 1b (Typically Generic):
$30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$125 copay
Specialty
30% after deductible, up to $250
Out-of-Network
Deductible (Individual/Family)
$250/$750
Out-of-Pocket Max (Individual/Family)
$7,500/$15,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$100 + 10% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a (Typically Lower Cost Generic):
50% coinsurance, up to $250
Tier 1b (Typically Generic):
50% coinsurance, up to $250
Preferred Brand
50% coinsurance, up to $250
Non-Preferred Brand
50% coinsurance, up to $250
Specialty
50% coinsurance, up to $250
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 Blue Cross EPO
Plan Information
Plan Name: Anthem Blue Cross EPO
Policy Number: L05224
Effective Date: 01/01/2025
Provider Network: Prudent Buyer 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 Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$40 copay
Urgent Care
$20 copay
Emergency Room
$150 copay + 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
Tier 1a: $5 copay
Tier 1b: $15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% after deductible, up to $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
Tier 1a: $10 copay
Tier 1b: $30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$125 copay
Specialty
30% after deductible, up to $250
Plan Documents
Contact Information
Kaiser HMO (CA Only)
Plan Information
Plan Name: Kaiser HMO (CA Only)
Policy Number: 607984
Effective Date: 01/01/2025
Provider Network: Kaiser Permanente
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 Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$30 copay
Urgent Care
$20 copay
Emergency Room
$200 per visit
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Specialty
N/A
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$90
Non-Preferred Brand
$90
Specialty
$200
Plan Documents
Contact Information
Kaiser HMO (HI Only)
Plan Information
Plan Name: Kaiser HMO (HI Only)
Policy Number: 18090
Effective Date: 01/01/2025
Provider Network: Kaiser Permanente
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 Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,500/$7,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$100 per visit
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$45 copay
Specialty
$200 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$90 copay
Specialty
N/A