the local choice: high deductible health plan (hdhp) info_d… · the local choice: high deductible...
TRANSCRIPT
1
of 8
The
Loca
l Cho
ice:
Hig
h D
educ
tible
Hea
lth P
lan
(HD
HP)
Cov
erag
e Pe
riod:
07/
01/2
014 –
06/3
0/20
15Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al/F
amily
|Pl
an T
ype:
PP
O
Que
stio
ns:C
all 1
-888
-642
-441
4 or
visi
t us a
t ww
w.th
eloc
alch
oice
.vir
gini
a.go
v.If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.thel
ocal
choi
ce.v
irgi
nia.
gov
or c
all 1
-888
-642
-441
4 to
requ
est a
cop
y.
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.thel
ocal
choi
ce.v
irgi
nia.
gov
or b
y ca
lling
1-8
88-6
42-4
414.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
For i
n-ne
twor
k pr
ovid
ers $
1,50
0pe
rson
/$3
,000
fam
ily
No
out-o
f-ne
twor
k be
nefit
s, ex
cept
in a
n em
erge
ncy
Doe
sn’t
appl
y to
pre
vent
ive
care
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins
to p
ay fo
r cov
ered
serv
ices
you
use
. Che
ck y
our p
olic
y or
pla
n do
cum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
m
eet t
he d
educ
tible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
don
’t ha
ve to
mee
t ded
uctib
les
for s
peci
fic se
rvic
es, b
ut se
e th
e ch
art
star
ting
on p
age
2 fo
r oth
er c
osts
for s
ervi
ces t
his p
lan
cove
rs.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. For
par
ticip
atin
g pr
ovid
ers $
5,00
0pe
rson
/$1
0,00
0fa
mily
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
yea
r) fo
r you
r sha
re o
f the
cos
t of c
over
ed se
rvic
es. T
his l
imit
help
s yo
u pl
an fo
r hea
lth c
are
expe
nses
. The
re a
re n
o ou
t-of-
netw
ork
bene
fits e
xcep
t in
an
emer
genc
y.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Ded
uctib
le a
nd c
oins
uran
ce fo
r rou
tine
dent
al se
rvic
es
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-po
cket
lim
it.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t th
e pl
an p
ays?
N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan
will
pay
for
specific
cov
ered
serv
ices
, suc
h as
off
ice
visit
s.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. See
ww
w.a
nthe
m.c
om o
r cal
l 1-
800-
552-
2682
for a
list
of i
n-ne
twor
k pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s pla
n w
ill p
ay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices
. Be
awar
e, y
our i
n-ne
twor
k do
ctor
or
hos
pita
l may
use
an
out-o
f-ne
twor
k pr
ovid
er fo
r som
e se
rvic
es. P
lans
use
th
e te
rm in
-net
wor
k, p
refe
rred
, or p
artic
ipat
ing
for p
rovi
ders
in th
eir
netw
ork .
See
the
char
t sta
rting
on
page
2 fo
r how
this
plan
pay
s diff
eren
t kin
ds
of p
rovi
ders
.
Do
I ne
ed a
refe
rral
to
see
a sp
ecia
list?
N
o. Y
ou d
on’t
need
a re
ferr
al to
see
a sp
ecia
list.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Page
22
2
of 8
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on
page
5. S
ee y
our
polic
y or
plan
doc
umen
t for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
Cop
aym
ents
are
fixe
d do
llar a
mou
nts (
for e
xam
ple,
$25)
you
pay
for c
over
ed h
ealth
car
e, us
ually
whe
n yo
u re
ceiv
e th
e se
rvic
e. C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice,
calcu
lated
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice.
For e
xam
ple,
if th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our d
educ
tible
. Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-
netw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffer
ence
. For
exa
mpl
e, if
an o
ut-o
f-net
wor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
ount
is $
1,00
0, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.) Th
is pl
an m
ay e
ncou
rage
you
to u
se in
-net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s.
Com
mon
Med
ical
Eve
ntSe
rvic
es Y
ou M
ay
Nee
dYo
ur C
ost I
f You
U
se a
n
In-N
etw
ork
Prov
ider
Your
Cos
t If Y
ou
Use
a
Non
-Net
wor
kPr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Spec
ialist
visi
t 20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
Oth
er p
ract
ition
er o
ffice
vi
sit
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
Cove
rage
is li
mite
d to
30
visit
s ann
ual m
ax fo
r ch
iropr
actic
. Pr
even
tive c
are/
sc
reen
ing/
imm
uniza
tion
No
char
ge
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray
, bl
ood
wor
k)
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Imag
ing
(CT/
PET
scan
s, M
RIs)
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
Pr
e-au
thor
izat
ion
may
be
requ
ired.
Page
23
3
of 8
C
omm
onM
edic
al E
vent
Serv
ices
You
May
N
eed
Your
Cos
t If Y
ou
Use
an
In
-Net
wor
k Pr
ovid
er
Your
Cos
t If Y
ou
Use
a
Non
-Net
wor
kPr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tr
eat y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out p
resc
riptio
n dr
ug c
over
age
is av
ailab
le a
t w
ww
.anth
em.co
m.
Gen
eric
dru
gs
20%
coi
nsur
ance
afte
r de
duct
ible
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Cove
rs u
p to
a 3
4-da
y su
pply
(ret
ail
pres
crip
tion)
; 90
day
supp
ly (h
ome
deliv
ery
pres
crip
tion)
. If y
ou u
se a
non
-net
wor
k ph
arm
acy,
you
pay
the
diffe
renc
e be
twee
n th
e ph
arm
acy
char
ge a
nd th
e pl
an a
llow
able
cha
rge.
Pref
erre
d br
and
drug
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le
20%
coi
nsur
ance
afte
r de
duct
ible
Pl
ease
see
limita
tions
in G
ener
ic d
rugs
.
Non
-pre
ferr
ed b
rand
dr
ugs
20%
coi
nsur
ance
afte
r de
duct
ible
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Plea
se se
e lim
itatio
ns in
Gen
eric
dru
gs.
Spec
ialty
dru
gs
20%
coi
nsur
ance
afte
r de
duct
ible
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Plea
se se
e lim
itatio
ns in
Gen
eric
dru
gs.
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bulat
ory
surg
ery
cent
er)
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
–––––––––––n
one–––––––––––
Phys
ician
/sur
geon
fees
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
–––––––––––n
one–––––––––––
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
. E
mer
genc
y se
rvice
s w
ill b
e co
nsid
ered
at
the
In-N
etw
ork
bene
fit
leve
l; ho
wev
er, b
alanc
e bi
lling
may
still
occ
ur.
–––––––––––n
one–––––––––––
Em
erge
ncy
med
ical
trans
porta
tion
20%
coi
nsur
ance
afte
r de
duct
ible
Not
Cov
ered
. E
mer
genc
y se
rvice
s w
ill b
e co
nsid
ered
at
the
In-N
etw
ork
bene
fit
leve
l; ho
wev
er, b
alanc
e bi
lling
may
still
occ
ur.
–––––––––––n
one–––––––––––
Urg
ent c
are
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
–––––––––––n
one–––––––––––
Page
24
4
of 8
If
you
hav
e a
hosp
ital s
tay
Faci
lity
fee
(e.g
., ho
spita
l ro
om)
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Phys
ician
/sur
geon
fee
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atie
nt se
rvic
es
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
Subs
tanc
e us
e di
sord
er
outp
atie
nt se
rvic
es
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Subs
tanc
e us
e di
sord
er
inpa
tient
serv
ices
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
Em
ploy
ee A
ssist
ance
Pr
ogra
m (E
AP)
N
o Ch
arge
N
ot C
over
ed
Cove
rs u
p to
4 v
isits
per
inci
dent
with
in a
12
mon
th p
erio
d.
If y
ou a
re p
regn
ant
Pren
atal
and
post
nata
l ca
re
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Del
iver
y an
d all
inpa
tient
se
rvic
es
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
care
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
Co
vera
ge is
lim
ited
to 9
0 vi
sits m
ax. p
er
cove
rage
per
iod.
Reha
bilit
atio
n se
rvic
es
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
Skill
ed n
ursin
g ca
re
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
Cove
rage
is li
mite
d to
180
day
s max
. per
co
vera
ge p
erio
d.
Dur
able
med
ical
equi
pmen
t 20
% c
oins
uran
ce a
fter
dedu
ctib
le
Not
Cov
ered
––
––––
––––
–non
e–––
––––
––––
Hos
pice
serv
ice
20%
coi
nsur
ance
afte
r de
duct
ible
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
Not
Cov
ered
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Glas
ses
Not
Cov
ered
N
ot C
over
ed
––––
––––
–––n
one–
––––
––––
––
Den
tal c
heck
-up
No
Char
ge
Prov
ider
Cha
rge
in
exce
ss o
f pla
n’s
cont
ract
ual r
ate
Den
tal c
over
age
adm
inist
ered
by
Del
ta D
enta
l of
Virg
inia,
ww
w.d
elta
dent
alva
.com
or c
all
1-88
8-33
5-82
96.
Page
25
5
of 8
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
Acu
punc
ture
Cosm
etic
surg
ery
Hea
ring
aids
Infe
rtilit
y tre
atm
ent
Long
-term
car
e
Rout
ine
eye
care
Rout
ine
foot
car
e (e
xcep
t for
som
e di
abet
ic
treat
men
t – p
leas
e se
e yo
ur m
embe
r ha
ndbo
ok fo
r com
plet
e de
tails
)
Wei
ght l
oss p
rogr
ams
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se
serv
ices
.)
Baria
tric
surg
ery
Chiro
prac
tic c
are
Den
tal c
are
Mos
t cov
erag
e pr
ovid
ed o
utsid
e th
e U
nite
d St
ates
. See
ww
w.an
them
.com
/tlc
Non
-em
erge
ncy
care
whe
n tra
velin
g ou
tsid
e th
e U
.S.
Priv
ate-
duty
nur
sing
Your
Rig
hts
to C
ontin
ue C
over
age:
If y
ou lo
se c
over
age
unde
r the
plan
, the
n, d
epen
ding
upo
n th
e ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
cove
rage
. Any
such
righ
ts m
ay b
e lim
ited
in d
urat
ion
and
will
requ
ire y
ou to
pay
a p
rem
ium
, whi
ch m
ay b
e sig
nific
antly
hig
her t
han
the
prem
ium
you
pay
w
hile
cov
ered
und
er th
e pl
an. O
ther
lim
itatio
ns o
n yo
ur ri
ghts
to c
ontin
ue c
over
age
may
also
app
ly.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, co
ntac
t the
plan
at 1
-888
-642
-441
4 . Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied
with
a d
enial
of c
over
age
for c
laim
s und
er y
our p
lan, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
qu
estio
ns a
bout
you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct:
Dire
ctor
, Dep
artm
ent o
f Hum
an R
esou
rce
Man
agem
ent,
101
Nor
th 1
4th S
treet
–
12th F
loor
, Ric
hmon
d, V
irgin
ia 23
219-
3657
. Mar
k en
velo
pe C
onfid
entia
l-App
eal E
nclo
sed.
Tel
epho
ne: 1
-888
-642
-441
4.
Page
26
6
of 8
D
oes
this
Cov
erag
e Pr
ovid
e M
inim
um E
ssen
tial C
over
age?
The
Aff
orda
ble
Car
e A
ct re
quire
s m
ost p
eopl
e to
hav
e he
alth
car
e co
vera
ge th
at q
ualif
ies
as “
min
imum
ess
entia
l cov
erag
e.”
Thi
s pl
an o
r pol
icy
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
Doe
s th
is C
over
age
Mee
t the
Min
imum
Val
ue S
tand
ard?
The
Aff
orda
ble
Car
e A
ct e
stab
lishe
s a m
inim
um v
alue
stan
dard
of b
enef
its o
f a h
ealth
pla
n. T
he m
inim
um v
alue
stan
dard
is 6
0% (a
ctua
rial v
alue
). T
his
heal
th c
over
age
does
mee
t the
min
imum
val
ue s
tand
ard
for
the
bene
fits
it pr
ovid
es.
Lang
uage
Acc
ess
Serv
ices
:
––––
––––
––––
––––
––––
––To
see e
xam
ples
of ho
w th
is pl
an m
ight c
over
costs
for a
sam
ple m
edica
l situ
ation
, see
the n
ext p
age.–––––––––––
––––
––––
–––
Page
27
7
of 8
Hav
ing
a ba
by
(nor
mal
deliv
ery)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e m
ainte
nanc
e of
a w
ell-c
ontro
lled
cond
ition
)
Abou
t the
se C
over
age
Exam
ples
: Th
ese
exam
ples
show
how
this
plan
mig
ht c
over
m
edica
l car
e in
giv
en si
tuat
ions
. Use
thes
e ex
ampl
es to
see,
in g
ener
al, h
ow m
uch
finan
cial
prot
ectio
n a s
ampl
e pa
tient
mig
ht g
et if
they
are
cove
red
unde
r diff
eren
t plan
s.
Amou
nt o
wed
to p
rovi
ders
: $7,
540
Plan
pay
s $4
,730
Pa
tient
pay
s $2
,810
Sam
ple
care
cos
ts:
Hos
pita
l cha
rges
(mot
her)
$2,7
00
Rout
ine
obste
tric
care
$2
,100
H
ospi
tal c
harg
es (b
aby)
$9
00
Ane
sthes
ia $9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diol
ogy
$200
V
accin
es, o
ther
pre
vent
ive
$40
Tot
al
$7,5
40
Patie
nt p
ays:
D
educ
tibles
$1
,500
Co
pays
$0
Co
insu
ranc
e $1
,160
Li
mits
or e
xclu
sions
$1
50
Tot
al
$2,8
10
Amou
nt o
wed
to p
rovi
ders
: $5,
400
Plan
pay
s $3
,070
Pa
tient
pay
s $2
,330
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
M
edica
l Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Proc
edur
es
$700
Ed
ucat
ion
$300
La
bora
tory
tests
$1
00
Vac
cines
, oth
er p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
D
educ
tibles
$1
,500
Co
pays
$0
Co
insu
ranc
e $7
50
Lim
its o
r exc
lusio
ns
$80
Tot
al
$2,3
30
This
is
not a
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
actu
al co
sts
unde
r thi
s plan
. The
actu
al ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the c
ost o
f th
at c
are
will
also
be
diffe
rent
.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
Page
28
8
of 8
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
Cos
ts d
on’t
incl
ude
prem
ium
s. Sa
mpl
e ca
re c
osts
are
bas
ed o
n na
tiona
l av
erag
es su
pplie
d by
the
U.S
. D
epar
tmen
t of H
ealth
and
Hum
an
Serv
ices
, and
are
n’t s
peci
fic to
a
parti
cular
geo
grap
hic
area
or h
ealth
plan
. Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pre
exist
ing
cond
ition
. A
ll se
rvic
es a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
Ther
e ar
e no
oth
er m
edic
al ex
pens
es fo
r an
y m
embe
r cov
ered
und
er th
is pl
an.
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on tr
eatin
g th
e co
nditi
on in
the
exam
ple.
The
patie
nt re
ceiv
ed a
ll ca
re fr
om in
-ne
twor
k pr
ovid
ers.
If t
he p
atie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-ne
twor
k pr
ovid
ers,
cos
ts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
For e
ach
treat
men
t situ
atio
n, th
e Co
vera
ge
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
als
o he
lps y
ou se
e w
hat e
xpen
ses m
ight
be
left
up to
you
to p
ay b
ecau
se th
e se
rvic
e or
tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
No.
Tre
atm
ents
show
n ar
e ju
st e
xam
ples
. Th
e ca
re y
ou w
ould
rece
ive
for t
his
cond
ition
cou
ld b
e di
ffer
ent b
ased
on
your
do
ctor
’s ad
vice
, you
r age
, how
serio
us y
our
cond
ition
is, a
nd m
any
othe
r fac
tors
. D
oes
the
Cov
erag
e Ex
ampl
e pr
edic
t my
futu
re e
xpen
ses?
No.
Cov
erag
e E
xam
ples
are
not
cos
t es
timat
ors.
You
can
’t us
e th
e ex
ampl
es to
es
timat
e co
sts f
or a
n ac
tual
cond
ition
. The
y ar
e fo
r com
para
tive
purp
oses
onl
y. Y
our
own
cost
s will
be
diff
eren
t dep
endi
ng o
n th
e ca
re y
ou re
ceiv
e, th
e pr
ices
you
r pr
ovid
ers
char
ge, a
nd th
e re
imbu
rsem
ent
your
hea
lth p
lan a
llow
s.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Yes
. Whe
n yo
u lo
ok a
t the
Sum
mar
y of
Be
nefit
s and
Cov
erag
e fo
r oth
er p
lans,
you’
ll fin
d th
e sa
me
Cove
rage
Exa
mpl
es.
Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “P
atie
nt P
ays”
box
in e
ach
exam
ple.
The
sm
aller
that
num
ber,
the
mor
e co
vera
ge
the
plan
pro
vide
s.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
yo
u pa
y. G
ener
ally,
the
low
er y
our
prem
ium
, the
mor
e yo
u’ll
pay
in o
ut-o
f-po
cket
cos
ts, s
uch
as c
opay
men
ts,
dedu
ctib
les,
and
coi
nsur
ance
. You
sh
ould
also
con
sider
con
tribu
tions
to
acco
unts
such
as h
ealth
savi
ngs a
ccou
nts
(HSA
s), f
lexi
ble
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HRA
s) th
at h
elp
you
pay
out-o
f-poc
ket
expe
nses
.
Page
29
HD
HP
Mon
thly
Rat
es
Hig
h D
educ
tible
Hea
lth P
lan
Em
ploy
ee O
nly
$0.0
0
Em
ploy
ee +
One
$158
.00
Fam
ily$3
03.0
0
Page
30
Page
31
���������3DJH���
Medical GOOCHLAND COUNTY PUBLIC SCHOOLS will offer Anthem medical benefits through The Local Choice (TLC). Please see the table below for a brief summary of coverage effective October 1, 2014. As always, please refer to the benefit summaries provided to you by TLC for further details on all benefits.
Option 1
Key Advantage 500 PPO
Option 2 Key Advantage 250
PPO
Option 3 High Deductible
Health Plan HMO
Referrals Required? No No No
Plan Year Deductible (October to October)
$500 individual $1,000 family
$250 individual $500 family
$1,500 individual$3,000 family
Maximum Out-of Pocket (Plan Year)
$3,000 individual $6,000 family
$2,000 individual $4,000 family
$5,000 individual$10,000 family
Office Visits (for illness or injury)
$25 PCP $40 Specialist
$20 PCP $35 Specialist
20% coinsurance, after deductible
Wellness Services (Well Child & Adult Preventive Care) Covered at 100%; No Charge Covered at 100%; No Charge Covered at 100%; No Charge
Inpatient Hospitalization 20% coinsurance, after deductible $300 copay per stay 20% coinsurance,
after deductible
Outpatient Hospitalization 20% coinsurance, after deductible $150 copay per visit 20% coinsurance,
after deductible
Emergency Room 20% coinsurance, after deductible $150 copay per visit 20% coinsurance,
after deductible
Pharmacy Prescription Drugs Tier 1 - $10 Tier 2 - $20 Tier 3 - $35
Tier 1 - $10 Tier 2 - $20 Tier 3 - $35
20% coinsurance, after deductible
Mail Order Prescription Drugs Tier 1 - $20 Tier 2 - $40 Tier 3 - $70
Tier 1 - $20 Tier 2 - $40 Tier 3 - $70
20% coinsurance, after deductible
Out-of-Network Benefits Yes Yes Only in emergency situations
Monthly Deduction (includes Medical, Dental & Vision)
Option 1 Key Advantage 500
Option 2 Key Advantage 250
Option 3 High Deductible
Health Plan
Employee $30.00 $73.00 $0.00
Employee + One $309.61 $389.61 $158.00
Employee + Family $559.38 $675.38 $303.00