APPENDIX A- WAGES. All members at the Rank of Assistant Chief will be paid 16% above the rank of District Fire Chief. Rank Annual Bi-Weekly 40-Hour Assistant Chief 110,275.40 4,241.3615 53.0170 EFFECTIVE SEPTEMBER 11, 2016 Rank Annual Bi-Weekly 40-Hour Assistant Chief 113,582.96 4,368.58 54.6072 EFFECTIVE JULY 2, 2017 Rank Annual Bi-Weekly 40-Hour Assistant Chief 116,990.45 4,499.63 56.2454 EFFECTIVE JULY 1, 2018 Rank Annual Bi-Weekly 40-Hour Assistant Chief 120,500.16 4,634.62 57.9328 ’Me-too’ with FOP on wages and any other percentage-based or across the board compensation in the form of supplemental or certification pay. APPENDIX B- HEALTH CARE PLANS TERMS OF COVERAGE For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share 7.5% 7.5% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2018 Single Family Premium Share 10% 10% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) For Assistant Chiefs hired after 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share 10% 10% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) Anthem Health Insurance Comparison Chart Effective January 1, 2011 BENEFIT BLUE ACCESS 80/20 Network Non-Network Level 200 Paycheck Deduction Deductions come out 1 month in advance. 7.5% deduction effective 1/1/2017 10.0% deduction effective 1/1/2018 Not applicable The benefits comparison sheet is meant to be a summary of your benefits only. Once a plan is selected, the Benefits Certificate will serve as the final document for detailing coverage. ALL CHARGES LISTED WITH A PERCENTAGE ARE FIRST SUBJECT TO AN ANNUAL DEDUCTIBLE. Maximum Annual Out of Pocket Single - $300 deductible then 20% coinsurance. Until you reach $1,200. Then coverage at 100%. Total = $1,500 Family - $600 deductible then 20% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Rx is not included above. Prescriptions always require a co-pay. Single - $600 deductible then 50% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Family - $1,200 deductible then 50% coinsurance. Until you reach $4,800. Then coverage at 100%. Total = $6,000 Rx is not included above. Prescriptions always require a co-pay. Network Sizes Approx. 1400 pcp and 2200 specialists Not applicable. Dependents (over age 19) Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Lifetime Max. amount per individual. $2 million combined. Network and non-network. $2 million combined. Network and non-network. Disease Man- agement Prog. Covered. Not covered. Maternity Deductible & then 20% co-insurance applies. Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Deductible & then 50% co-insurance applies.Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Mental Health Providers Blue Access uses the Anthem Behavioral Health Network. Go to xxx.Xxxxxx.xxx for providers or call 0-000-000-0000 No referral needed. See inpatient &/or outpatient treatment of mental/nervous disorders for amounts of co- pays. Office Calls Deductible & then 20% co-insurance applies. Deducible & then 50% co-insurance applies. Prescription Drugs Member pharmacy-30 day supply$10-formulary generic$20-formulary brand name$30-non-formulary brand name Mail Order-90 day supply $20-formulary generic$40-formulary brand name$60-non-formulary brand nameSupplies for diabetes and asthma clients may be covered from 80% up to 100%. Covered at 50%.Does not count for out of pocket maximums Mail Order - not covered Referrals No referrals needed unless physician requires it. Routine Mammograms & Routine PAP testing Covered in full. Deductible & then 50% co-insurance applies. Routine Hearing Evaluation Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Routine Vision Exam Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Wellness/ Preventive (physical exams) & Immunizations Covered in full. Deductible & then 50% co-insurance applies. Alcoholism/ Drug Addiction Inpatient Substance Abuse programs are limited to 2 per lifetime. Limited to 30 days per confinement. Inpatient care must be pre-certified. Deductible & then 20% co-insurance applies. 50 Outpatient visits. Visits are combined with Mental Health. Deductible & then 50% co-insurance applies. Inpatient & outpatient substance abuse programs (limit of 2 per lifetime) Combined with mental health. Allergy Treatment Testing & treatment Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Anesthesia Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Blood Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Chiropractor (Spinal manipulation services) Deductible & then 20% co-insurance applies. Limit 12 visits per year. Deductible & then 50% co-insurance applies. Limit 12 visits per year combined with network. Durable Medical & Surgical Supplies Deductible & then 20% co-insurance applies. Certain supplies are covered under prescription drug card. Does NOT cover general items such as bandages, thermometers, etc. May need claim form. Deductible & then 50% co-insurance applies. Certain supplies are not covered.Does NOT cover general itemssuch as bandages thermometers, etc. May need claim form. Emergency Room Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Home Health Care Deductible & then 20% co-insurance applies. Custodial care is not covered under any plan. Deductible & then 50% co-insurance applies. Non-network is limited to 30 visits. Custodial care is not covered under any plan. Hospital Inpatient Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Hospice Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Infertility Deductible & then 20% co-insurance applies. Applicable co-pays depends on place of service & covered to diagnosis. Fertility treatment is not covered. Deductible & then 50% co-insurance applies. Only to diagnosis. Fertility treatment is not covered. Inpatient Hospital Medical/ Surgical Stay Deductible & then 20% co-insurance applies. No annual day limit, length of stay based on medical necessity. Must have authorization to admission for scheduled admissions. 60 day limit on stays for physical medicine and rehab. Deductible & then 50% co-insurance applies. No annual day limit, length of stay based on medical necessity. Must have authorization to admission for scheduled admissions.60 day limit on stays for physical medicine and rehab. Inpatient Treatment of Mental/ Nervous Disorders Limited to 30 days annually.Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Limited to 30 days annually. Local Ambulance Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Maxillary or Mandibular Osteotomies of Tempro- Mandibular Joint dysfunction (TMJ) Deductible & then 20% co-insurance applies if medically necessary and authorized in advance. Deductible & then 50% co-insurance applies. If medically necessary and authorized in advance. Oral Surgery Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Out-of-area Emergency Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Out patient diagnostic services Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Hemodialysis Deductible & then 20% co-insurance applies Deductible & then 50% co-insurance applies. Out patient Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Treatment of Mental/ Nervous Disorders Limited to 50 visits annually.Deductible & then 20% co-insurance applies. Limited to 50 visits annually combined with network.Deductible & then 50% co-insurance applies. Physical Therapy and Occupational Therapy Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 20% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)), Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 50% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)). Pre-admission testing Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Private duty nursing Deductible & then 20% co-insurance applies. Must be pre-approved Deductible & then 50% co-insurance applies. Must be pre-approved. Prosthetic Devices/ Durable Medical Equipment Deductible & then 20% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Deductible & then 50% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Radiotherapy& Chemotherapy Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Skilled Nursing Facility Deductible & then 20% co-insurance applies. Days must be pre-authorized. Deductible & then 50% co-insurance applies. Days must be pre-authorized. Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Surgical Assistance Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Urgent Care Center Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Transplants - Kidney, Cornea, heart, lung & pancreas, liver. Covered in full.$1 million lifetime maximum applies. Deductible & then 50% co-insurance applies. Does not apply towards out of pocket maximums. Tissue Transplant Including Bone Marrow $1 million lifetime maximums applies, combined with network. If you go out-of-network, the City cannot control the doctor's offices from balance billing for any differences between what Anthem pays and what Anthem states is your co-pay.
Appears in 2 contracts
Samples: Management Agreement, Management Agreement
APPENDIX A- WAGES. All members at the Rank of Assistant Chief will be paid 16% above the rank of District Fire Chief. Rank Annual Bi-Weekly 40-Hour Assistant Chief 110,275.40 4,241.3615 53.0170 EFFECTIVE SEPTEMBER 11, 2016 Rank Annual Bi-Weekly 40-Hour Assistant Chief 113,582.96 4,368.58 54.6072 EFFECTIVE JULY 2, 2017 Rank Annual Bi-Weekly 40-Hour Assistant Chief 116,990.45 4,499.63 56.2454 EFFECTIVE JULY 1, 2018 Rank Annual Bi-Weekly 40-Hour Assistant Chief 120,500.16 4,634.62 57.9328 ’Me-too’ with FOP on wages and any other percentage-based or across the board compensation in the form of supplemental or certification pay. APPENDIX B- HEALTH CARE PLANS TERMS OF COVERAGE For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share Single 7.5% Family 7.5% Deductible Network $300 $600 Co-insurance Out-of-pocket Non-network Network Non-network Network $600 $1,200 Co-insurance Network 20% to $1,200 2050% to $2,400 Non-network 50$1,500 $1,200 20% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) $10/$20/$30 $10/$20/$30 For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2018 Single Family Premium Share Single 10% Family 10% Deductible Network $300 $600 Co-insurance Out-of-pocket Non-network Network Non-network Network $600 $1,200 Co-insurance Network 20% to $1,200 2050% to $2,400 Non-network 50$1,500 $1,200 20% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) $10/$20/$30 $10/$20/$30 For Assistant Chiefs hired after 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share Single 10% Family 10% Deductible Network $300 $600 Co-insurance Out-of-pocket Non-network Network Non-network Network $600 $1,200 Co-insurance Network 20% to $1,200 2050% to $2,400 Non-network 50$1,500 $1,200 20% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) Anthem Health Insurance Comparison Chart Effective January 1, 2011 BENEFIT BLUE ACCESS 80/20 Network Non-Network Level 200 Paycheck Deduction Deductions come out 1 month in advance. 7.5% deduction effective 1/1/2017 10.0% deduction effective 1/1/2018 Not applicable The benefits comparison sheet is meant to be a summary of your benefits only. Once a plan is selected, the Benefits Certificate will serve as the final document for detailing coverage. ALL CHARGES LISTED WITH A PERCENTAGE ARE FIRST SUBJECT TO AN ANNUAL DEDUCTIBLE. Maximum Annual Out of Pocket Single - $300 deductible then 20% coinsurance. Until you reach $1,200. Then coverage at 100%. Total = $1,500 Family - $600 deductible then 20% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Rx is not included above. Prescriptions always require a co-pay. Single - $600 deductible then 50% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Family - $1,200 deductible then 50% coinsurance. Until you reach $4,800. Then coverage at 100%. Total = $6,000 Rx is not included above. Prescriptions always require a co-pay. Network Sizes Approx. 1400 pcp and 2200 specialists Not applicable. Dependents (over age 19) Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Lifetime Max. amount per individual. $2 million combined. Network and non-network. $2 million combined. Network and non-network. Disease Man- agement Prog. Covered. Not covered. Maternity Deductible & then 20% co-insurance applies. Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Deductible & then 50% co-insurance applies.Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Mental Health Providers Blue Access uses the Anthem Behavioral Health Network. Go to xxx.Xxxxxx.xxx for providers or call 0-000-000-0000 No referral needed. See inpatient &/or outpatient treatment of mental/nervous disorders for amounts of co- pays. Office Calls Deductible & then 20% co-insurance applies. Deducible & then 50% co-insurance applies. Prescription Drugs Member pharmacy-30 day supply$10-formulary generic$20-formulary brand name$30-non-formulary brand name Mail Order-90 day supply $20-formulary generic$40-formulary brand name$60-non-formulary brand nameSupplies for diabetes and asthma clients may be covered from 80% up to 100%. Covered at 50%.Does not count for out of pocket maximums Mail Order - not covered Referrals No referrals needed unless physician requires it. Routine Mammograms & Routine PAP testing Covered in full. Deductible & then 50% co-insurance applies. Routine Hearing Evaluation Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Routine Vision Exam Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Wellness/ Preventive (physical exams) & Immunizations Covered in full. Deductible & then 50% co-insurance applies. Alcoholism/ Drug Addiction Inpatient Substance Abuse programs are limited to 2 per lifetime. Limited to 30 days per confinement. Inpatient care must be pre-certified. Deductible & then 20% co-insurance applies. 50 Outpatient visits. Visits are combined with Mental Health. Deductible & then 50% co-insurance applies. Inpatient & outpatient substance abuse programs (limit of 2 per lifetime) Combined with mental health. Allergy Treatment Testing & treatment Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Anesthesia Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Blood Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Chiropractor (Spinal manipulation services) Deductible & then 20% co-insurance applies. Limit 12 visits per year. Deductible & then 50% co-insurance applies. Limit 12 visits per year combined with network. Durable Medical & Surgical Supplies Deductible & then 20% co-insurance applies. Certain supplies are covered under prescription drug card. .Does NOT cover general items such as bandages, thermometers, etc. May need claim form. Deductible & then 50% co-insurance applies. Certain supplies are not covered.Does NOT cover general itemssuch as bandages thermometers, etc. May need claim form. Emergency Room Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Home Health Care Deductible & then 20% co-insurance applies. Custodial care is not covered under any plan. Deductible & then 50% co-insurance applies. Non-network is limited to 30 visits. Custodial care is not covered under any plan. Hospital Inpatient Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Hospice Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Infertility Deductible & then 20% co-insurance applies. Applicable co-pays depends on place of service & covered to diagnosis. Fertility treatment is not covered. Deductible & then 50% co-insurance applies. Only to diagnosis. .Fertility treatment is not covered. Inpatient Hospital Medical/ Surgical Stay Deductible & then 20% co-insurance applies. No annual day limit, length of stay based on medical necessity. .Must have authorization to admission for scheduled admissions. 60 day limit on stays for physical medicine and rehab. Deductible & then 50% co-insurance applies. No annual day limit, length of stay based on medical necessity. Must have authorization to admission for scheduled admissions.60 admissions. 60 day limit on stays for physical medicine and rehab. Inpatient Treatment of Mental/ Nervous Disorders Limited to 30 days annually.Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Limited to 30 days annually. Local Ambulance Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Maxillary or Mandibular Osteotomies of Tempro- Mandibular Joint dysfunction (TMJ) Deductible & then 20% co-insurance applies if medically necessary and authorized in advance. Deductible & then 50% co-insurance applies. If medically necessary and authorized in advance. Oral Surgery Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Out-of-area Emergency Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Out patient diagnostic services Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Hemodialysis Deductible & then 20% co-insurance applies Deductible & then 50% co-insurance applies. Out patient Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Treatment of Mental/ Nervous Disorders Limited to 50 visits annually.Deductible & then 20% co-insurance applies. Limited to 50 visits annually combined with network.. Deductible & then 50% co-insurance applies. Physical Therapy and Occupational Therapy Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 20% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)), Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 50% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)). Pre-admission testing Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Private duty nursing Deductible & then 20% co-insurance applies. Must be pre-approved Deductible & then 50% co-insurance applies. Must be pre-approved. Prosthetic Devices/ Durable Medical Equipment Deductible & then 20% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Deductible & then 50% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Radiotherapy& Chemotherapy Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Skilled Nursing Facility Deductible & then 20% co-insurance applies. Days must be pre-authorized. Deductible & then 50% co-insurance applies. Days must be pre-authorized. Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Surgical Assistance Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Urgent Care Center Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Transplants - Kidney, Cornea, heart, lung & pancreas, liver. Covered in full.$1 million lifetime maximum applies. Deductible & then 50% co-insurance applies. Does not apply towards out of pocket maximums. Tissue Transplant Including Bone Marrow $1 million lifetime maximums applies, combined with network. If you go out-of-network, the City cannot control the doctor's offices from balance billing for any differences between what Anthem pays and what Anthem states is your co-pay.
Appears in 2 contracts
APPENDIX A- WAGES. All members at the Rank of Assistant Chief will be paid 16% above the rank of District Fire Chief. Rank Annual Bi-Weekly 40-Hour Assistant Chief 110,275.40 4,241.3615 53.0170 EFFECTIVE SEPTEMBER 11, 2016 Rank Annual Bi-Weekly 40-Hour Assistant Chief 113,582.96 4,368.58 54.6072 EFFECTIVE JULY 2, 2017 Rank Annual Bi-Weekly 40-Hour Assistant Chief 116,990.45 4,499.63 56.2454 EFFECTIVE JULY 1, 2018 Rank Annual Bi-Weekly 40-Hour Assistant Chief 120,500.16 4,634.62 57.9328 ’Me-too’ with FOP on wages and any other percentage-based or across the board compensation in the form of supplemental or certification pay. APPENDIX B- HEALTH CARE PLANS TERMS OF COVERAGE For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share 7.5% 7.5% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) For Assistant Chiefs hired prior to 4/27/2016, EFFECTIVE January 1, 2018 Single Family Premium Share 10% 10% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) For Assistant Chiefs hired after 4/27/2016, EFFECTIVE January 1, 2017 Single Family Premium Share 10% 10% Deductible Network $300 $600 Non-network $600 $1,200 Co-insurance Network 20% to $1,200 20% to $2,400 Non-network 50% to $2,400 50% to $4,800 Out-of-pocket Network $1,500 $3,000 Maximum Non-network $3,000 $6,000 Prescriptions $10/$20/$30 $10/$20/$30 (generic/brand/non-formulary) Anthem Health Insurance Comparison Chart Effective January 1, 2011 BENEFIT BLUE ACCESS 80/20 Network Non-Network Level 200 Paycheck Deduction Deductions come out 1 month in advance. 7.5% deduction effective 1/1/2017 10.0% deduction effective 1/1/2018 Not applicable The benefits comparison sheet is meant to be a summary of your benefits only. Once a plan is selected, the Benefits Certificate will serve as the final document for detailing coverage. ALL CHARGES LISTED WITH A PERCENTAGE ARE FIRST SUBJECT TO AN ANNUAL DEDUCTIBLE. Maximum Annual Out of Pocket Single - $300 deductible then 20% coinsurance. Until you reach $1,200. Then coverage at 100%. Total = $1,500 Family - $600 deductible then 20% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Rx is not included above. Prescriptions always require a co-pay. Single - $600 deductible then 50% coinsurance. Until you reach $2,400. Then coverage at 100%. Total = $3,000 Family - $1,200 deductible then 50% coinsurance. Until you reach $4,800. Then coverage at 100%. Total = $6,000 Rx is not included above. Prescriptions always require a co-pay. Network Sizes Approx. 1400 pcp and 2200 specialists Not applicable. Dependents (over age 19) Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Unmarried children to end of the year age 24, if main residence is with subscriber & are eligible as Federal tax exemptions. Lifetime Max. amount per individual. $2 million combined. Network and non-network. $2 million combined. Network and non-network. Disease Man- agement Prog. Covered. Not covered. Maternity Deductible & then 20% co-insurance applies. Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Deductible & then 50% co-insurance applies.Dependent female children are covered for maternity benefits. Their newborn will be covered after legal guardianship is obtained. Mental Health Providers Blue Access uses the Anthem Behavioral Health Network. Go to xxx.Xxxxxx.xxx for providers or call 0-000-000-0000 No referral needed. See inpatient &/or outpatient treatment of mental/nervous disorders for amounts of co- pays. Office Calls Deductible & then 20% co-insurance applies. Deducible & then 50% co-insurance applies. Prescription Drugs Member pharmacy-30 day supply$10-formulary generic$20-formulary brand name$30-non-formulary brand name Mail Order-90 day supply $20-formulary generic$40-formulary brand name$60-non-formulary brand nameSupplies for diabetes and asthma clients may be covered from 80% up to 100%. Covered at 50%.Does not count for out of pocket maximums Mail Order - not covered Referrals No referrals needed unless physician requires it. Routine Mammograms & Routine PAP testing Covered in full. Deductible & then 50% co-insurance applies. Routine Hearing Evaluation Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Routine Vision Exam Covered in full. One routine test covered per year. Deductible & then 50% co-insurance applies. Wellness/ Preventive (physical exams) & Immunizations Covered in full. Deductible & then 50% co-insurance applies. Alcoholism/ Drug Addiction Inpatient Substance Abuse programs are limited to 2 per lifetime. Limited to 30 days per confinement. Inpatient care must be pre-certified. Deductible & then 20% co-insurance applies. 50 Outpatient visits. Visits are combined with Mental Health. Deductible & then 50% co-insurance applies. Inpatient & outpatient substance abuse programs (limit of 2 per lifetime) Combined with mental health. Allergy Treatment Testing & treatment Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Anesthesia Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Blood Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Chiropractor (Spinal manipulation services) Deductible & then 20% co-insurance applies. Limit 12 visits per year. Deductible & then 50% co-insurance applies. Limit 12 visits per year combined with network. Durable Medical & Surgical Supplies Deductible & then 20% co-insurance applies. Certain supplies are covered under prescription drug card. Does NOT cover general items such as bandages, thermometers, etc. May need claim form. Deductible & then 50% co-insurance applies. Certain supplies are not covered.Does NOT cover general itemssuch as bandages thermometers, etc. May need claim form. Emergency Room Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Home Health Care Deductible & then 20% co-insurance applies. Custodial care is not covered under any plan. Deductible & then 50% co-insurance applies. Non-network is limited to 30 visits. Custodial care is not covered under any plan. Hospital Inpatient Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Hospice Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Infertility Deductible & then 20% co-insurance applies. Applicable co-pays depends on place of service & covered to diagnosis. Fertility treatment is not covered. Deductible & then 50% co-insurance applies. Only to diagnosis. Fertility treatment is not covered. Inpatient Hospital Medical/ Surgical Stay Deductible & then 20% co-insurance applies. No annual day limit, length of stay based on medical necessity. Must have authorization to admission for scheduled admissions. 60 day limit on stays for physical medicine and rehab. Deductible & then 50% co-insurance applies. No annual day limit, length of stay based on medical necessity. Must have authorization to admission for scheduled admissions.60 day limit on stays for physical medicine and rehab. Inpatient Treatment of Mental/ Nervous Disorders Limited to 30 days annually.Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Limited to 30 days annually. Local Ambulance Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Maxillary or Mandibular Osteotomies of Tempro- Mandibular Joint dysfunction (TMJ) Deductible & then 20% co-insurance applies if medically necessary and authorized in advance. Deductible & then 50% co-insurance applies. If medically necessary and authorized in advance. Oral Surgery Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Deductible & then 20% co-insurance applies. Expenses will be covered if for repair to an injury as a result of an accident. For initial repair of an injury to jaw, sound natural teeth, mouth or face which are required as a result of an accident. Initial repair must be within 12 months. Out-of-area Emergency Deductible & then 20% co-insurance applies. Deductible & then 20% co-insurance applies. Out patient diagnostic services Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Hemodialysis Deductible & then 20% co-insurance applies Deductible & then 50% co-insurance applies. Out patient Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Out patient Treatment of Mental/ Nervous Disorders Limited to 50 visits annually.Deductible & then 20% co-insurance applies. Limited to 50 visits annually combined with network.Deductible & then 50% co-insurance applies. Physical Therapy and Occupational Therapy Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 20% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)), Physical & occupational- Outpatient (60 visit limit annually) Deductible & then 50% co-insurance applies. Inpatient (60 days for physical med. & rehab. (annual)). Pre-admission testing Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Private duty nursing Deductible & then 20% co-insurance applies. Must be pre-approved Deductible & then 50% co-insurance applies. Must be pre-approved. Prosthetic Devices/ Durable Medical Equipment Deductible & then 20% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Deductible & then 50% co-insurance applies. Repair or replacement due to growth or additional needs of affected member is subject to medical necessity Radiotherapy& Chemotherapy Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Skilled Nursing Facility Deductible & then 20% co-insurance applies. Days must be pre-authorized. Deductible & then 50% co-insurance applies. Days must be pre-authorized. Surgery Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Surgical Assistance Deductible & then 20% co-insurance applies. If medically necessary. Deductible & then 50% co-insurance applies. If medically necessary. Urgent Care Center Deductible & then 20% co-insurance applies. Deductible & then 50% co-insurance applies. Transplants - Kidney, Cornea, heart, lung & pancreas, liver. Covered in full.$1 million lifetime maximum applies. Deductible & then 50% co-insurance applies. Does not apply towards out of pocket maximums. Tissue Transplant Including Bone Marrow $1 million lifetime maximums applies, combined with network. If you go out-of-network, the City cannot control the doctor's offices from balance billing for any differences between what Anthem pays and what Anthem states is your co-pay.
Appears in 1 contract
Samples: Management Agreement
