Group Forms Anthem

APPLICATIONS

 
Anthem 2014 Plans
Plan Name (Reference #) Network Office Visit Copay Prescription Deductible & Coinsurance Out-of-Pocket Limit
GJHA Gold (A-1) PPO $20/$40 $15/$35/$70/25% $2000 + 40% $4000 Ind/$8000 Family
GZPA Gold (A-2) PPO $20 (3 visits) SELECT $15/$35/$70/30% $500 + 20% $3000 Ind/$6000 Family
GFHA Gold (A-3) PPO $25/$50 $15/$35/$70/25% $1500 + 20% $4000 Ind/$8000 Family
GZPA Gold w/dental (A-4) PPO $20 (3 visits) SELECT $15/$35/$70/30% $500 + 20% $3000 Ind/$6000 Family
GHLA Gold (A-5) PPO $20/$40 $250 Ded, $15/$35/$70/30% $750 + 20% $4500 Ind/$9000 Family
GFGA Gold (A-6) PPO $25/$50 $15/$35/$70/25% $1000 + 20% $3500 Ind/$7000 Family
GPKA Gold (A-7) PPO $25/$50 $15/$35/$70/25% $500 + 20% $4500 Ind/$9000 Family
GJPA Silver (A-8) PPO $35 (3 visits) SELECT $500 Ded, $15/$35/$70/30% $3000 + 30% $5500 Ind/$11,000 Family
GGQA Silver (A-9) PPO $50 (3 visits) SELECT $250 Ded, $15/$35/$70/30% $2000 + 30% $5000 Ind/$10,000 Family
GCQA Silver (A-10) PPO $35 (3 visits) SELECT $250 Ded, $15/$35/$70/30% $1500 + 30% $4250 Ind/$8500 Family
GGQA Silver w/dental (A-11) PPO $50 (3 visits) SELECT $250 Ded, $15/$35/$70/30% $2000 + 30% $5000 Ind/$10,000 Family
GYIA Silver (A-12) PPO $50/$75 $250 Ded, $15/$35/$70/30% $2000 + 50% $6350 Ind/$12.700 Family
GRDF Bronze (A-13) PPO $35 (3 visits) SELECT $450 Ded, $15/$35/$70/30% $5900 + 0% $6350 Ind/$12,700 Fam + Rx
GTPA Bronze (A-14) PPO $35 (3 visits) SELECT $250 Ded, $15/$35/$70/30% $4000+ 30% $6350 Ind/$12.700 Fam + Rx
GPSA Silver HSA (A-15) PPO Ded & Coinsurance Ded & Coinsurance $2500 + 20% $4500 Ind/$9000 Family
GDSA Silver HSA (A-16) PPO Deductible Deductible $3500 + 0% $3500 Ind/$7000 Family
GHHB Bronze HSA (A-17) PPO Deductible then $50/$75 SELECT, Deductible, $15/$35/$70/30% $4500 + 30% $6350 Ind/$12,700 Family
GPDB Bronze HSA (A-18) PPO Ded & Coinsurance Ded & Coinsurance $2500 + 50% $6350 Ind/$12,700 Family
GMUA Bronze HSA (A-19) PPO Deductible Deductible $5500 + 0% $5500 Ind/$11,000 Family
GMCA Gold (A-20) Blue Priority HMO $20/$40 SELECT $250 Ded, $15/$35/$70/30% $1000 + 20% $4500 Ind/$9000 Family
GPJA Silver (A-21) Blue Priority HMO $50/$75 $250 Ded, $15?$35/$70/25% $1750 + 40% $6350 Ind/$12,700 Family
GCDA Silver (A-22) Blue Priority HMO $25/$50 SELECT $250 Ded, $15/$35/$70/30% $2500 + 20% $6000 Ind/$12,000 Family
GNEA Silver (A-23) Blue Priority PPO $30/$60 or $60/$100 SELECT $500 Ded, $15/$35/$70/30% $2500 + 20% $6000 Ind/$12,000 Family
GJQA Bronze (A-24) Blue Priority HMO $35 (3 visits) SELECT $15/$35/$70/30% $5000 + 30% $6350 Ind/$12,700 Fam + Rx
GJQA Bronze w/dental (A-25) Blue Priority HMO $35 (3 visits) SELECT $15/$35/$70/30% $5000 + 30% $6350 Ind/$12,700 Fam + Rx
GFDA Gold (A-26) Pathway HMO $10/$35 SELECT $15/$35/$70/30% $1500 + 20% $4000 Ind/$8000 Family
GMPA Gold (A-27) Pathway HMO $20 (3 visits) SELECT $15/$35/$70/30% $500 + 20% $5000 Ind/$10,000 Family
GHPA Silver (A-28) Pathway HMO $30 (3 visits) SELECT $500 Ded, $15/$35/$70/30% $4000 + 0% $4500 Ind/$9000 Family
GZCA Silver (A-29) Pathway HMO $25/$50 SELECT $500 Ded, $15/$35/$70/30% $3000 + 20% $6000 Ind/$12,000 Family
GZIA Silver (A-30) Pathway HMO $50/$75 $250 Ded, $15/$35/$70/25% $4000 + 20% $6350 Ind/$12,700 Family
GGJA Silver (A-31) Pathway HMO $30/$60 $250 Ded, $15/$35/$70/25% $2500 + 20% $6350 Ind/$12,700 Family
 
CURRENT PLANS
Health Plan Name SBC Office Visit
Copay
Prescriptions Deductible & Coinsurance Out-of-Pocket
Limit
PPO $1250 B 0LJB SBC Not Covered $15 Generic Only $1250 + 30% $4750
PPO $1000 B 0LJC SBC $50/$75 $15 Generic Only $1000 + 30% $4000
PPO $1500 G 0NCF SBC $50/$75 $15 Generic Only $1500 + 40% $6000
PPO $750 G 0NCE SBC $45/$75 $15 Generic Only $750 + 40% $4750
PPO $2000 X0LJD SBC $30/$60 $1000 Deductible,
then $15/$40/$60/30%
$2000 + 30% $5000
PPO $3000 X 0LJE SBC $30/$60 $1000 Deductible,
then $15/$40/$60/30%
$3000 + 30% $6000
PPO $5000 S 0NCD $40/$60 $15/$40/$60/30% $5000 + 30% $8000
PPO $3000 S 0NCC SBC $30/$60 $15/$40/$60/30% $3000 + 30% $6000
PPO $2000 S 0NCB SBC $30/$60 $15/$40/$60/30% $2000 + 30% $5000
PPO $1500 S 0NCA SBC $25/$50 $15/$40/$60/30% $1500 + 20% $4000
PPO $1000 S 0NC9 SBC $25/$50 $15/$40/$60/30% $1000 + 20% $4000
PPO $500 S 0NC8 SBC $20/$40 $15/$40/$60/30% $500 + 20% $3500
HSA $5000 100% 073X SBC Deductible Deductible, then
$15/$40/$60/30%
$5000 + Rx Copays $6000 including
Rx Copays
HSA $3000 80% 073W SBC Deductible &
Coinsurance
Deductible &
Coinsurance
$3000 + 20% $6000
HSA $2000 80% 074G SBC Deductible &
Coinsurance
Deductible &
Coinsurance
$2000 + 20% $6000
HRA $5000 0FF3 SBC $40/$60 Deductible, then
$15/$40/$60/30%
$5000 + 20% $8000
HRA $4000 0FF1 SBC $30/$60 Deductible, then
$15/$40/$60/30%
$4000 + 20% $6000
HRA $3000 0FEZ SBC $25/$50 Deductible, then
$15/$40/$60/30%
$3000 + 20% $5000
HMO Select $45/$1500 074F $45/$60 $15 Generic Only $1500 + 40% $6500
HMO Select $40/$1000 074E $40/$60 $15/$40/$60/30% $1000 + 30% $5000
Classic HMO Select 074D $25/$50 $15/$40/$60/30% None $3000
Classic HMO 074C $25/$50 $15/$40/$60/30% None $3000
Blue Priority HMO $1000 $10/$50 $10/$50/$75/30% $1000 + 20% $4000 + Deductible
Blue Priority HMO $1500 $10/$50 $1000 Deductible, then
$10/$50/$75/30%
$1500 + 20% $4500 + Deductible
Blue Priority HMO $2000 $10/$50 $15 Generic Only $2000 + 20% $5000 + Deductible
Blue Priority PPO $1000 $10/$50 $10/$50/$75/30% $1000 + 20% $4000 + Deductible
Blue Priority PPO $2000 $10/$50 $1000 Deductible, then
$10/$50/$75/30%
$2000 + 20% $5000 + Deductible
RETIRED PLANS
Health Plan Name Office Visit
Copay
Prescriptions Deductible &
Coinsurance
Out-of-Pocket
Limit
PPO Copay $45 GenRx $45/$75 $15 Generic Only $750 + 40% $4750
Copay $35/$75 GenRx $35/$75 $15 Generic Only $500 + 30% $4000
PPO Copay $50/75 GenRx $50/$75 $15 Generic Only $1500 + 40% $6000
PPO Copay $40/$60 $5000 Deductible $40/$60 $15/$40/$60/30% $5000 + 30% $8000
PPO Copay $30/$60 $3000 Deductible $30/$60 $15/$40/$60/30% $3000 + 30% $6000
PPO Copay $30/60 $2000 Deductible $30/$60 $15/$40/$60/30% $2000 + 30% $5000
PPO $25/$50 $1500 Deductible $25/$50 $15/$40/$60/30% $1500 + 20% $4000
PPO $25/$50 $1000 Deductible $25/$50 $15/$40/$60/30% $1000 + 20% $4000
PPO $20/$40 $500 Deductible $20/$40 $15/$40/$60/30% $500 + 20% $3500
Lumenos HSA $2000 Deductible 90% Deductible &
Coinsurance
Deductible &
Coinsurance
$2000 + 10% $5000
Lumenos HSA $2000 Deductible 80% Deductible &
Coinsurance
Deductible &
Coinsurance
$2000 + 20% $5000
Lumenos HSA $3000 Deductible 90% Deductible &
Coinsurance
Deductible &
Coinsurance
$3000 + 10% $5000
Lumenos HSA $3000 Deductible 80% Deductible &
Coinsurance
Deductible &
Coinsurance
$3000 + 20% $5000
Lumenos HSA $3000 Deductible 100% Deductible Deductible, then
$15/$40/$60/30%
$3000 $4000 incl.
Rx copays
Lumenos HSA $5000 Deductible 100% Deductible Deductible, then
$15/$40/$60/30%
$5000 $5800 incl.
Rx copays
Classic HMO $25/$50 $15/$40/$60/30% None $3000
Classic HMO Select $25/$50 $15/$40/$60/30% None $3000
HMO Select $45 Copay GenRx $45/$60 $15 Generic Only $1500 + 30% $5500
HMO Select Copay $40 $40/$60 $15/$40/$60/30% $1000 + 20% $5000
BENEFITS PLANS
Health Plan Name SBC Office Visit
Copay
Prescriptions Deductible &
Coinsurance
Out-of-Pocket
Limit
Hospital Benefits Not Covered $15 Generic Only $1250 + 30% $4250
Hospital Benefits Plus $50/$75 $15 Generic Only $1000 + 30% $4000
Hospital Benefits Preferred $50/$75 $15 Generic Only $750 + 30% $3750
PPO Copay $45 GenRx $45/$75 $15 Generic Only $750 + 40% $4750
Lumenos HSA $3000 Deductible 100% Deductible Deductible, then
$15/$40/$60/30%
$3000 $4000 incl.
Rx Copays
HMO Select $45 Copay GenRx $45/$60 $15 Generic Only $1500 + 30% $5500
PPO Copay $30/60 $2000 Deductible $30/$60 $15/$40/$60/30% $2000 + 30% $5000
STATE MANDATED
PLANS
Standard PPO $30/$50 $15/$40/$60 $1500 + 20% $4500
Basic PPO $40/$60 $150 Deductible,
then $20/$50/$70
$4000 + 30% $10,000
Standard HMO $30/$50 $15/$40/$60 Copays $4500
Basic HMO $40/$60 $150 Deductible,
then $20/$50/$70
Copays $10,000