to view all linked information and videos in this guide

To view all linked information and videos in this guide, visit http://envisionbenefitsguide.com/

http://envisionbenefitsguide.com



http://envisionhealthcarebenefits.com

PPO Select PPO Primary HSA Select HSA Primary HSA Base

Deductible

In-Network:$600 individual$1,200 family Out-of-Network:$1,200 individual$2,400 family (embedded)

In-Network: $1,100 individual $2,200 familyOut-of-Network: $2,200 individual $4,400 family (embedded)

In-Network:$1,600 individual$3,200 family Out-of-Network:$3,200 individual$6,400 family (non-embedded)

In-Network:$3,100 individual$6,200 family Out-of-Network:$6,200 individual$12,400 family (embedded)

In-Network:$6,650 individual$13,300 family Out-of-Network:$13,300 individual$26,600 family (embedded)

Coinsurance (Plan Pays)

In-Network: 90%Out-of-Network: 70%





Out-of-Pocket Maximum1

In-Network:$3,300 individual$6,600 family Out-of-Network:$12,000 individual$24,000 family




In-Network:$6,650 individual$13,300 familyOut-of-Network:$25,800 individual$51,600 family

HSA Contribution2 N/A N/A $500 individual$1,000 family

$300 individual$600 family N/A

(PCP/Specialist)

In-Network:$25 PCP / $50 SPC(deductible waived)Out-of-Network: 70%





In-Network: 80% In-Network: 70% In-Network: 100%Telemedicine: LiveHealth Online

$30 copay (deductible waived)

$30 copay (deductible waived)

Inpatient Hospital In-Network: 90%Out-of-Network: 70%





Outpatient Surgery In-Network: 90%Out-of-Network: 70%





Emergency Room In-Network: $200 copayOut-of-Network: $200 copay

In-Network: $250 copayOut-of-Network: $250 copay




Urgent CareIn-Network: $50 copay (deductible waived)Out-of-Network: 70%

In-Network: $60 copay (deductible waived)Out-of-Network: 60%




Mental Health/Substance Abuse Inpatient




Mental Health/Substance Abuse Outpatient

1 Deductibles, coinsurance and copays (where applicable) accumulate toward the medical out-of-pocket maximum.2The Company HSA contribution is available only to teammates in salary bands I and II.

Medical Coverage Options

The following table provides a side-by-side comparison of the benefits available under each medical plan. This summary is an overview of benefits and not a contract. For a detailed listing of benefits, go to EnvisionHealthcareBenefits.com








PPO Select PPO Primary HSA Select HSA Primary HSA Base

Generic: $10 copay

Brand Formulary: $50 copay

Brand Non-Formulary: $75 copay

Specialty: 20% coinsurance

(Not subject to deductible but expenses paid by you count toward your medical plan’s annual out-of-pocket maximum.)

Generic: $15 copay

Brand Formulary: $60 copay

Brand Non-Formulary: $80 copay

Specialty: 20% coinsurance

(Not subject to deductible but expenses paid by you count toward your medical plan’s annual out-of-pocket maximum.)

20% coinsurance after deductible

Generic: 20% coinsurance after deductible

Brand Formulary: 30% coinsurance after deductible

Brand Non-Formulary: 50% coinsurance after deductible

Specialty: 30% coinsurance after deductible

100% coverage after deductible

Prescription Coverage


60019CAMENABC_MPS VPOD 06/17

When you’re not feeling well you can get the support you need easily using LiveHealth Online. Whether you have a cold, you’re feeling anxious or need help managing your medication, doctors and mental health professionals are right there, ready to help you feel your best. Using LiveHealth Online you can have a video visit with a board-certified doctor, psychiatrist or licensed therapist from your smartphone, tablet or computer from home or anywhere.

On LiveHealth Online, you can:

See a board-certified doctor 24/7. You don’t need an appointment to see a doctor. They’re always available to assess your condition and send a prescription to the pharmacy you choose, if needed.1 It’s a great option when you have pink eye, a cold, the flu, a fever, allergies, a sinus infection or another common health issue.

Visit a licensed therapist in four days or less.2 Have a video visit with a therapist to get help with anxiety, depression, grief, panic attacks and more. Schedule your appointment online or call 1-888-548-3432 from 8 a.m. to 8 p.m., seven days a week.

Consult a board-certified psychiatrist within two weeks.3 If you’re over 18 years old, you can get medication support to help you manage a mental health condition. To schedule your appointment call 1-888-548-3432 from 8 a.m. to 8 p.m., seven days a week.

You’ve got access to affordable and convenient care

Your Anthem plan includes benefits for video visits using LiveHealth Online, so you’ll just pay your share of the costs.

G morf troppus te d dna stsipareht ,srotco p .emityna stsirtaihcysUse LiveHealth Online, anytime, for a private video visit with a doctor or mental health professional.

Sign up for LiveHealth Online today -- it’s quick and easy Go to livehealthonline.com or download the app and register on your phone or tablet.


http://envisionhealthcarebenefits.com

to view all linked information and videos in this guide

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