CITY OF LAMAR 4 Administered by County Health Pool (CHP)-Anthem Network Comprehensive and preventive healthcare coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. The City of Lamar offers you a choice of two (2) plans: a PPO Plan and a High Deductible Health Plan (HDHP). With the Preferred Provider Organization (PPO) plan, you and your family members may visit any licensed provider but will receive the greatest out-of-pocket savings if you see an in-network provider. If you choose to see an out-of-network provider, you will incur additional out-of-pocket expenses, and you may be billed for the difference in the cost of the services (called balance billing). When you see an in-network provider, you are protected from balance billing. The High Deductible Health Plan (HDHP) option is a qualified plan for a Health Savings Account (HSA). With an HSA, you are able to set aside pre-tax funds into an account to be used for qualified medical expenses. For more information on how your HSA works, please see the HSA section of this booklet. To find an in-network provider, please visit www.anthem.com, select the “Individual & Family”, click on “Find a Doctor” and select the Preferred PPO Provider Network. PPO B2000 PLAN HDHP W/ HSA 2500 Plan In-Network Out-of-Network In-Network Out-of-Network Calendar-Year Deductible (single/family) $2,000 / $4,000 $4,000 / $8,000 $2,500 / $5,000 $5,000 / $10,000 Calendar-Year Out-of-Pocket Maximum (single/family) $5,250 / $12,000 $10,000 / $26,000 $5,000 / $6,850 $10,000 / $20,000 Coinsurance 20% 40% 20% 40% DOCTOR’S OFFICE Primary Care Office Visit $35 copay then 20% after deductible 40% after deductible 20% after deductible 40% after deductible Specialist Office Visit $35 copay 20% after deductible 40% after deductible 20% after deductible 40% after deductible Preventive Care 100% Covered 40%, no deductible 100% Covered 40%, no deductible PRESCRIPTION DRUGS—RETAIL 30-DAY SUPPLY/ MAIL ORDER 90-DAY SUPPLY Prescription Drug Deductible $75 per person Not covered N/A Not covered Retail - Generic Drug $10 copay or 20% of cost, whichever is greater 20% after deductible Retail - Formulary Drug $25 copay or 30% of cost, whichever is greater 20% after deductible Retail - Non-formulary Drug $35 copay or 50% of cost, whichever is greater 20% after deductible Mail Order - All Tiers $25/$60/$115 copay 20% after deductible MEDICAL & PHARMACY
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