Page 6 - Quarles

Medical Benefits

You have two medical plan options through Anthem Blue Cross and Blue
Shield. The following table compares key features in each plan. Each plan has a
provider network that charges negotiated fees. See page 7 for contribution rates.

Comparing Medical Plan Options

What You Pay

Anthem KeyCare PPO Plan Anthem HealthKeepers HMO Plan

Features In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
$300 $450 $0 $750
Individual $600 $900 $0 $1,500
Family
$3,500 $4,000 $4,000 $5,000
Annual Out-of-Pocket $7,000 $8,000 $8,000 $10,000
Maximum* 40%
$0 $0 30%
Individual 20% 40%
Family after deductible after deductible $20 copay 30%
20% $40 copay after deductible
Preventive Care after deductible 40% $200 copay
Doctor’s Office Visit 20% after deductible $300 copay per day 30%
after deductible up to $1,500 per after deductible
Primary Care Physician 40% admission
Specialist 20% after deductible 30%
after deductible after deductible
Prenatal and postnatal 40%
care for maternity 20% after deductible 20% 30%
Maternity delivery and after deductible after deductible
inpatient services 40%
Advanced 20% after deductible $20 copay 30%
Imaging MRI, after deductible $200 copay after deductible
MRA, PET, CT 20% (waived if admitted to
Urgent Care (per visit) 20% after deductible the hospital) $200 copay
after deductible no deductible
Emergency 40% (waived if admitted to
Room (per visit) after deductible
the hospital)
Outpatient Surgery
Ambulatory Center $250 copay 30%
after deductible

Outpatient 20% 40% $250 copay 30%
Surgery Hospital after deductible after deductible $300 copay per day after deductible
Inpatient Hospital
Durable Medical 20% 40% up to $1,500 per 30%
after deductible after deductible admission after deductible
20%
20% 40% 30%
after deductible after deductible after deductible

*Includes deductible, coinsurance, copays and eligible prescription drug expenses.

5 2016-2017 Benefits Guide