Buy Up Plan

Similar to the Basic Plan but a Higher Price Per Pay Period
The Buy Up Plan could be a good option if you use medical services often, since the deductible and annual out-of-pocket amounts are lower and coinsurance is higher. It is built on the same platform as the Basic Plan, but has more coverage in some of the areas you use frequently. However, you will pay more out of your paycheck for this coverage.

Summary of In-Network Benefits

Annual Deductible

Associate only: $250
Associate + 1: $500
Associate + 2 or more: $750
*There is an additional hospital deductible for
$250 per inpatient stay

Preventive Care
(e.g., well baby and well adult including gynecology)
100% of services covered by Anthem preventive care standards per covered family member, not subject to deductible or copay
Office Visits (non-routine)

$25 copay for primary physician
$40 copay for specialist

Emergency Room
$100 copay per occurence
Services also subject to the annual deductible and coinsurance

Coinsurance for Most Services
(your out-of-pocket cost after the deductible and emergency room copay)

You pay 10% (Plan pays 90%)
Coinsurance Limit
(the most you will pay in coinsurance for the year)
Associate only: $2,000
Associate + 1: $4,000
Associate + 2 or more: $6,000

Vision

Covered
(see your Benefits Overview for specifics)

Prescription (Medco participating pharmacies only)

          
          Retail (30-day supply)



          Mail Order (90-day supply)



There is a $100 deductible for retail brand prescriptions

Generic: $10 copay
Preferred Brand: You pay 20%
Non-Preferred Brand: You pay 40%

Generic: $30 copay
Preferred Brand: You pay 20%
Non-Preferred Brand: You pay 40%

Notes: The Buy Up Plan will begin covering most services once a covered individual meets the individual deductible ($250). For “Associate + 2 or more” coverage, only three covered family members need to meet the deductible for services to be covered for all covered family members.

The office visit and emergency room copay and prescription drug copay/coinsurance do not apply to the medical deductible or coinsurance limit. Coinsurance amounts are subject to the PPO negotiated rate for in-network services as determined by the claims administrator. Mental/nervous and substance abuse for the Plan is administered by CIGNA Behavioral Health. Minimum and maximum charges for prescription coinsurances do apply.

This is intended to be a summary of benefits. See your Benefits Overview or Summary Plan Description for specifics of this Plan.