Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
PIH Health Plan
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$20 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (Up to 90-Day Supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
Not covered
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$45 copay
Urgent Care
$30 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – MedImpact (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – MedImpact (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
Not covered
PIH Health CDHP
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Individual in a Family/Family)
$1,700/$3,400/$3,400
Out-of-Pocket Max (Individual/Individual in a Family/Family)
$3,400/$3,400/$6,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
20% after deductible
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (30-90 day supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
Not covered
Tier 3: Out-of-Network Providers
Deductible (Individual/Individual in a Family/Family)
$4,000/$4,000/$8,000
Out-of-Pocket Max (Individual/Individual in a Family/Family)
$10,000/$10,000/$20,000
Preventive Care
Not covered
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
25% coinsurance + $20 copay
Preferred Brand
25% coinsurance + $45 copay
Non-Preferred Brand
25% coinsurance + $100 copay
Specialty
25% coinsurance + $20 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Individual in a Family/Family)
$2,500/$3,400/$5,000
Out-of-Pocket Max (Individual/Individual in a Family/Family)
$6,000/$6,000/$12,000
Preventive Care
$0
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
20% after deductible
Retail Rx – MedImpact (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – MedImpact (Up to 90-Day Supply)
Generic
$40 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
Not covered
PIH Health EPO
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Individual in a Family/Family)
$0/$0/$0
Out-of-Pocket Max (Individual/Individual in a Family/Family)
$3,000/$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$20 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (30-90 day supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
Not covered
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Individual in a Family/Family)
$1,000/$1,000/$2,000
Out-of-Pocket Max (Individual/Individual in a Family/Family)
$6,000/$6,000/$12,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
$30 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$30 copay (deductible waived)
Emergency Room
$150 copay (waived if admitted)
Retail Rx – MedImpact (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – MedImpact (Up to 90-Day Supply)
Generic
$40 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
Not covered