Common use of Anchor Plan Clause in Contracts

Anchor Plan. In Network Deductible* $1,000 ($2,000 family) In Network Out of Pocket Max** $2,000 ($4,000 family) Out of Network Deductible $2,000 ($4,000 family) Out of Network Out of Pocket Max $6,000 ($12,000 family) In-Network Coinsurance 10% Out of Network Coinsurance 30% *The family deductible is cumulative, meaning any combination of items covered by the deductible paid by family members counts toward the deductible until the full amount of the deductible has been met. **The in-network out-of-pocket maximum is a combined out-of-pocket maximum with the pharmacy out-of-pocket maximum. 1) The following in-network copays shall be in effect for the Anchor Plan: Preventative care office visits are covered in full; 2) Office visit (non-preventative) PCP - $15 copay; 3) Specialist office visit - $25/$50 copay (higher specialist copay applies without referral under PCP Coordination of Care); 4) Chiropractic care -$15 copay; 5) Diagnostic tests (X-rays, blood work) – no charge; 6) Imaging (CT/PET Scans, MRIs) – coinsurance applies after deductible. (Covered in full after deductible if an imaging center is used); 7) Inpatient hospital- coinsurance after deductible; 8) Outpatient surgery- coinsurance after deductible; 9) Mental Health/Substance Use Disorder – in-patient: coinsurance after deductible, outpatient: $15 copay; 10) Emergency room - $150 copay; 11) Ambulance – Covered in full; 12) Urgent care- $50 copay; 13) Physical therapy, occupational therapy and speech therapy -$15 copay.

Anchor Plan. In Network Deductible* $1,000 ($2,000 family) In Network Out of Pocket Max** Out of Network Deductible Out of Network Out of Pocket Max In-Network Coinsurance Out of Network Coinsurance $1,000 ($2,000 family) $2,000 ($4,000 family) Out of Network Deductible $2,000 ($4,000 family) Out of Network Out of Pocket Max $6,000 ($12,000 family) In-Network Coinsurance 10% Out of Network Coinsurance 30% *The family deductible is cumulative, meaning any combination of items covered by the deductible paid by family members counts toward the deductible until the full amount of the deductible has been met. **The in-network out-of-pocket maximum is a combined out-of-pocket maximum with the pharmacy out-of-pocket maximum. 1) . The following in-network copays shall be in effect for the Anchor Plan: : (1) Preventative care office visits are covered in full; (2) Office visit (non-preventative) PCP - $15 copay; (3) Specialist office visit - $25/$50 copay (higher specialist copay applies without referral under PCP Coordination of Care); (4) Chiropractic care -$15 - $15 copay; (5) Diagnostic tests (X-rays, blood work) – work)- no charge; (6) Imaging (CT/PET Scans, MRIs) – MRis)- coinsurance applies after deductible. (Covered in full after deductible if an imaging center is used); (7) Inpatient hospital- coinsurance after deductible; (8) Outpatient surgery- surgery - coinsurance after deductible; (9) Mental Health/Substance Use Disorder – Disorder- in-patient: coinsurance after deductible, outpatient: $15 copay; (10) Emergency room - $150 copay; (11) Ambulance – Covered Ambulance- covered in full;: (12) Urgent care- care - $50 copay; (13) Physical therapy, occupational therapy and speech therapy -$15 - $15 copay.

Anchor Plan. In Network Deductible* $1,000 ($2,000 family) In Network Out of Pocket Max** $2,000 ($4,000 family) Out of Network Deductible $2,000 ($4,000 family) Out of Network Out of Pocket Max $6,000 ($12,000 family) In-Network Coinsurance 10% Out of Network Coinsurance 30% *The family deductible is cumulative, meaning any combination of items covered by the deductible paid by family members counts toward the deductible until the full amount of the deductible HSA has been met. **The in-network out-of-pocket maximum is a combined out-of-pocket maximum with the pharmacy out-of-pocket maximum. 1) . The following in-network copays shall be in effect for the Anchor Plus Plan: : 1) Preventative care office visits are covered in full; 2) Office visit (non-preventative) PCP - $15 copay; 3) Specialist office visit - $25/$50 copay (higher specialist copay applies without referral under PCP Coordination of Care); 4) Chiropractic care -$15 - $15 copay; 5) Diagnostic tests (X-rays, blood work) – no charge; 6) Imaging (CT/PET Scans, MRIs) – coinsurance applies after deductible. deductible (Covered covered in full after deductible if an imaging center is used); 7) Inpatient hospital- hospital – coinsurance after deductible; 8) Outpatient surgery- surgery - coinsurance after deductible; 9) Mental Health/Substance Use Disorder – in-in patient: coinsurance after deductible, outpatient: $15 copay; 10) Emergency room - $150 125 copay; 11) Ambulance – Covered covered in full; 12) Urgent care- care - $50 copay; 13) Physical therapy, occupational therapy and speech therapy -$15 - $15 copay.

Anchor Plan. In In-Network Deductible* $1,000 ($2,000 family) In In-Network Out of Out-of-Pocket Max** $2,000 ($4,000 family) Out of Out-of-Network Deductible $2,000 ($4,000 family) Out of Out-of-Network Out of Out-of-Pocket Max $6,000 ($12,000 family) In-Network Coinsurance Co-insurance 10% Out of Out-of-Network Coinsurance Co-insurance 30% *The family deductible is cumulative, meaning any combination of items covered by the deductible paid by family family-members counts toward the deductible until the full amount of the deductible has been met. **The in-network out-of-pocket maximum is a combined out-of-pocket maximum with the pharmacy out-of-pocket maximum. 1) . The following in-network copays co-pays shall be in effect for the Anchor Plan: : 1) Preventative care office visits are covered in full; 2) Office visit (non-preventative) PCP - $15 copayco-pay; 3) Specialist office visit - $25/$50 copay co-pay (higher specialist copay co-pay applies without referral under PCP Coordination of Care); 4) Chiropractic care -$15 copay- $15 co-pay; 5) Diagnostic tests (X-rays, blood work) – no charge; 6) Imaging (CT/PET Scans, MRIs) – coinsurance co-insurance applies after deductible. (Covered in full after deductible if an imaging center is used); 7) Inpatient hospital- coinsurance hospital – co-insurance after deductible; 8) Outpatient surgery- coinsurance surgery – co-insurance after deductible; 9) Mental Health/Substance Use Disorder – in-patient: coinsurance co-insurance after deductible, outpatient: $15 copayco-pay; 10) Emergency room - $150 copayco-pay; 11) Ambulance – Covered - covered in full;: 12) Urgent care- care - $50 copayco-pay; 13) Physical therapy, occupational therapy and speech therapy -$15 copay- $15 co-pay.

Anchor Plan. In Network Deductible* $1,000 ($2,000 family) In Network Out of Pocket Max** Out of Network Deductible Out of Network Out of Pocket Max In-Network Coinsurance Out of Network Coinsurance $1,000 ($2,000 family) $2,000 ($4,000 family) Out of Network Deductible $2,000 ($4,000 family) Out of Network Out of Pocket Max $6,000 ($12,000 family) In-Network Coinsurance 10% Out of Network Coinsurance 30% *The family deductible is cumulative, meaning any combination of items covered by the deductible paid by family members counts toward the deductible until the full amount of the deductible has been met. **The in-network out-of-pocket maximum is a combined out-of-pocket maximum with the pharmacy out-of-pocket maximum. 1) . The following in-network copays shall be in effect for the Anchor Plan: : (1) Preventative care office visits are covered in full; (2) Office visit (non-preventative) PCP - $15 copay; (3) Specialist office visit - $25/$50 copay (higher specialist copay applies without referral under PCP Coordination of Care); (4) Chiropractic care -$15 - $15 copay; (5) Diagnostic tests (X-rays, blood work) – - no charge; (6) Imaging (CT/PET Scans, MRIs) – - coinsurance applies after deductible. (Covered in full after deductible if an imaging center is used); (7) Inpatient hospital- hospital - coinsurance after deductible; (8) Outpatient surgery- surgery - coinsurance after deductible; (9) Mental Health/Substance Use Disorder – Disorder- in-patient: coinsurance after deductible, outpatient: $15 copay; 10) Emergency ; (10)Emergency room - $150 copay; 11) Ambulance – Covered in full; 12) Urgent care- $50 copay; 13) Physical therapy, occupational therapy and speech therapy -$15 copay.