Plan Details
Plan Name	Anthem HDHP
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$1,650	$1,650
Annual Deductible/Family	$3,300	$3,300
Coinsurance	10%	50%
Office Visit/Exam	10% after deductible	50% after deductible
Outpatient Specialist Visit	10% after deductible	50% after deductible
Annual Out-of-Pocket Limit/Individual	$4,000	$6,000
Annual Out-of-Pocket Limit/Family	$10,000	$12,000
Preventive Care	0%	50% after deductible
Inpatient Hospitalization	10% after deductible	50% after deductible
Surgical Services Outpatient Facility Charge	10% after deductible	50% after deductible
Emergency Room	10% after deductible	10% after deductible
Urgent Care Facility	10% after deductible	50% after deductible
Prescription Drug Deductible	combined with medical deductible	combined with medical deductible
Prescription Drugs - Generic	$10 after deductible	30% after deductible
Prescription Drugs - Brand (Formulary/Preferred)	$30 after deductible	30% after deductible
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50 after deductible	30% after deductible
Prescription Drugs - Specialty	30% up to $100 after deductible	Not Covered
Chiropractic Services	covered up to 60 visits per year combined with all other therapies	covered up to 60 visits per year combined with all other therapies
Acupuncture	$30 up to 20 visits per year	$30 up to 20 visits per year