Medical

We offer an EPO [Exclusive Provider Organization/in-network only] plan, a PPO plan and a PPO plan that is HSA eligible. (See Summary of Benefits).

Pharmacy

Medical Documents

2024 Medical Benefits

2024 SBC – Basic EPO with Rx

2024 SBC – Basic EPO with Rx (Spanish)

2024 SBC – Employee High Deductible HSA with Rx

2024 SBC – Employee High Deductible HSA with Rx (Spanish)

2024 SBC – Employee Plus High Deductible HSA with Rx

2024 SBC – Employee Plus High Deductible HSA with Rx (Spanish)

2024 SBC – High Deductible PPO with Rx

2024 SBC – High Deductible PPO with Rx (Spanish)

High Deductible PPO Plan Booklet

Employee Plus HSA Plan Booklet

Basic EPO Plan Booklet

Pharmacy Summary of Benefits

EXPRESS-SCRIPTS NETWORK PHARMACY	PPO	PPO WITH HSA	BASIC EPO
Preventive Prescriptions Tier 1 – Generic Tier 2 – Preferred Brand Drugs Tier 3 – Non-Preferred Brand Mail Order or Retail – 90 Day Supply	No Deductible, you pay $5 Copay $10 Copay $10 Copay 3x Retail Copay	No Deductible, you pay $5 Copay $10 Copay $10 Copay 3x Retail Copay	No Deductible, you pay $5 Copay $10 Copay $10 Copay 3x Retail Copay
Retail – 30 Day Supply Tier 1 – Generic Tier 2 – Preferred Brand Drugs Tier 3 – Non-Preferred Brand	No Deductible, you pay: $15 Copay $35 Copay $70 Copay	After Deductible, you pay: 20% coinsurance 30% coinsurance 40% coinsurance	No Deductible, you pay: $15 Copay $35 Copay $70 Copay
Mail Order or Retail – 90 Day Supply Tier 1 – Generic Tier 2 – Preferred Brand Drugs Tier 3 – Non-Preferred Brand	No Deductible, you pay: $45 Copay $105 Copay $210 Copay	After your Deductible, you pay: 20% coinsurance 30% coinsurance 40% coinsurance	No Deductible, you pay: $45 Copay $105 Copay $210 Copay
Specialty Medication (30 day Maximum)	No Deductible, you pay: $250 Copay	After your Deductible, you pay: 25% coinsurance to a maximum of $250 per prescription per month	No Deductible, you pay: $250 Copay

Telemedicine

Are you on vacation? Stuck home with the kids? Is it 3 a.m. and you need care now? No problem. With Anthem’s Live HealthOnline doctors are available 24 hours a day, seven days a week, 365 days a year to address your minor health concerns including: