This plan grid offers a summary of the plans. Please refer to the Benefit Summaries for further details.

Anthem Blue Cross and Blue Shield

and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue
Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Medical Plan Comparison
Prepared on August 22nd, 2014
All benefits are subject to the Benefit Period Deductible, except those with in-network copays, unless otherwise noted.
PLAN COMPARISON
Note:
All benefits are listed below as
"member pays".
Anthem Preferred
DirectAccess w/HSA
gtqa
Anthem Preferred
DirectAccess gkfa
In-network
Deductible Individual $2,000* $2,000
Deductible Family $4,000* $4,000
Out-of-pocket maximum -
individual**
$2,000 $3,500
Out-of-pocket maximum -
family**
$4,000 $7,000
Coinsurance 0% 20%
Office Visit(PCP) Copay 0% $30
Office Visit(specialist) Copay 0% $60
Retail Health Clinic Copay 0% $20
Urgent Care Copay 0% $60
Emergency Room Copay 0% $200 + 20%
Inpatient - facility 0% 20%
Outpatient surgery - facility 0% 20%
Out-of-network
Deductible (individual/family) $4,000 / $8,000 $4,000 / $8,000
Out-of-pocket maximum
(individual/family)**
$6,000 / $12,000 $7,000 / $14,000
Coinsurance 30% 30%
Pharmacy
Deductible
Combined with Medical
Ded
N/A
Tier 1 - Retail Ded/0% $10
Tier 2 - Retail Ded/0% $30
Tier 3 - Retail Ded/0%
Greater of 25%
coinsurance-$60 copay
Tier 1 - Home Delivery Ded/0% $25
Tier 2 - Home Delivery Ded/0% $75
Tier 3 - Home Delivery Ded/0%
Greater of 25%
coinsurance-$150 copay
Tier 4 - Home Delivery Ded/0% N/A
* These are non-embedded deductible products. When it comes to deductibles, its important to understand the difference between
an embedded deductible versus a non-embedded deductible. With an embedded deductible, each family member has an individual
deductible/out-of-pocket amount. Any deductible amount contributed by an individual will apply to the family deductible amount, but
no individual family member is required to contribute more to the family deductible than their individual deductible amount. The
out-of-pocket accumulates on an embedded basis as well With a non-embedded deductible product, all family members have a
This plan grid offers a summary of the plans. Please refer to the Benefit Summaries for further details. Anthem Blue Cross and Blue Shield
and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue
Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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shared deductible and out-of-pocket family maximum. The entire deductible must be satisfied before coverage can begin for any
individual family member. And, the entire out-of-pocket maximum must be satisfied before the family has satisfied the out-of-pocket
maximum.
** Deductibles are included in the Out-of-pocket maximum amounts.