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PPO $2500 SBC
PPO $5000 SBC
HSA $3500 SBC
HSA $5000 SBC
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Meridian Healthcare offers a choice between four medical plans through Anthem Blue Cross Blue Shield. The chart below is a brief outline of the plans. Please refer to the summary plan description for complete plan details. The plan year begins July 1st.

Your plan allows you to see any network provider without a physician referral. The level of benefits you receive is dependent upon your choice of using a network or a non-network provider. Significantly higher benefits will be received when you obtain care from a participating network provider. Please see www.anthem.com to locate a “Blue Access PPO” network provider or download the Anthem Sydney mobile app. To find out what tier applies to a specific medication, review the Essential Drug List at www.anthem.com/pharmacyinformation/.

Medical Per Pay Cost*

  PPO $2500 PPO $5000 HSA $3500 HSA $5000
  Wellness Non-Wellness Wellness Non-Wellness Wellness Non-Wellness Wellness Non-Wellness
Employee Only $58.41 $83.41 $51.32 $76.32 $26.23 $51.23 $0.00 $25.00
Employee & Spouse $130.26 $180.26 $114.43 $164.43 $58.50 $108.50 $0.00 $50.00
Employee & Child(ren) $118.58 $143.58 $104.17 $129.17 $53.25 $78.25 $0.00 $25.00
Family $186.33 $236.33 $163.69 $213.69 $83.68 $133.68 $0.00 $50.00

*NOTE: The spousal surcharge of $150.00 was not applied to the monthly cost or contribution above.

Spousal Surcharge (Medical Plan Only)

If your spouse has coverage available elsewhere through his or her employer, and you elect to cover him or her on the Meridian HealthCare plan, there will be a $150.00 per month surcharge applied. If you are enrolling your spouse, the surcharge will automatically be applied. If enrolling your spouse on our medical plan, please complete the Affidavit of Spousal Employment & Health Care Coverage within EBM/Plansource.

Cash Opt-Out Plan

If you elect to waive any and/or all of the medical plans offered to you by Meridian HealthCare, you will receive the following amounts according to what you elect. To participate in this Cash Opt-Out Plan, you must provide a copy of your other health insurance card showing proof that you have insurance available to you from some other source.

Single = $900/year or ($37.50/pay) 
Family = $1,800/year or ($75/pay) 

Based on 24 pays per year.

PPO 2500 (3-tier)

Services Preferred Network In-Network  Out-of-Network
Calendar Year Deductible (Embedded) $2,500 individual
$5,000 family		 $5,000 individual
$10,000 family		 $22,500 individual
$45,000 family
Annual Out-of-Pocket Maximum $6,600 individual
$13,200 family		 $23,100 individual
$46,200 family
Coinsurance 0% after Deductible 20% after Deductible 50% after Deductible
Primary Care Visits $20 Copay $35 Copay 50% after Deductible
Preventive Care Covered at 100% Covered at 100% 50% after Deductible
Specialist Visits $40 Copay $70 Copay 50% after Deductible
Emergency Room $350 Copay, then 20%
Urgent Care 0% after Deductible 20% after Deductible 50% after Deductible
Inpatient Hospital 0% after Deductible 20% after Deductible 50% after Deductible
Outpatient Surgery 0% after Deductible 20% after Deductible 50% after Deductible
Lab / X-Ray / MRI 0% after Deductible 20% after Deductible 50% after Deductible
Prescription Drug Coverage – In-Network Retail Pharmacy (30 Day Supply)
Generic (Tier 1) Level 1 Pharmacy: $10 Copay / Level 2 Pharmacy: $20 Copay
Preferred (Tier 2) Level 1 Pharmacy: $40 Copay / Level 2 Pharmacy: $50 Copay
Non-Preferred (Tier 3) Level 1 Pharmacy: $70 Copay / Level 2 Pharmacy: $80 Copay
Preferred Specialty (Tier 4) Level 1 Pharmacy: 25% up to $350 maximum
Level 2 Pharmacy: 25% up to $450 maximum
Mail Order Pharmacy (90 Day Supply)
Generic (Tier 1) $25 Copay
Preferred (Tier 2) $100 Copay
Non-Preferred (Tier 3) $175 Copay
Preferred Specialty (Tier 4) Level 1 Pharmacy: 25% up to $350 maximum
Level 2 Pharmacy: Not Covered

Level 1 Pharmacies include popular chains such as Target, CVS, Walmart, Giant Eagle and 25,000 other retailers.
Level 2 Pharmacies include popular chains such as Rite Aid and Walgreens. Logon to Anthem.com to locate your preferred pharmacy.

Logon to Anthem.com to locate your preferred pharmacy.

**Deductibles, coinsurance and copayments (medical and prescription drug) accumulate toward the Out-Of-Pocket Maximum.
*Out-of-network retail pharmacy is covered at 50% after the deductible. Out-of-network mail order pharmacy is not covered.

PPO $5000 (3-tier)

Services Preferred Network In-Network  Out-of-Network
Calendar Year Deductible (Embedded) $5,000 individual
$10,000 family		 $8,000 individual
$16,000 family		 $22,500 individual
$45,000 family
Annual Out-of-Pocket Maximum $9,450 individual
$18,900 family		 $24,500 individual
$48,900 family
Coinsurance 0% after Deductible 20% after Deductible 50% after Deductible
Primary Care Visits $20 Copay $35 Copay 50% after Deductible
Preventive Care Covered at 100% Covered at 100% 50% after Deductible
Specialist Visits $40 Copay $70 Copay 50% after Deductible
Emergency Room $350 Copay, then 20%
Urgent Care 0% after Deductible 20% after Deductible 50% after Deductible
Inpatient Hospital 0% after Deductible 20% after Deductible 50% after Deductible
Outpatient Surgery 0% after Deductible 20% after Deductible 50% after Deductible
Lab / X-Ray / MRI 0% after Deductible 20% after Deductible 50% after Deductible
Prescription Drug Coverage – In-Network Retail Pharmacy (30 Day Supply)
Generic (Tier 1) Level 1 Pharmacy: $10 Copay
Level 2 Pharmacy: $20 Copay
Preferred (Tier 2) Level 1 Pharmacy: $40 Copay / Level 2 Pharmacy: $50 Copay
Non-Preferred (Tier 3) Level 1 Pharmacy: $70 Copay / Level 2 Pharmacy: $80 Copay
Preferred Specialty (Tier 4) Level 1 Pharmacy: 25% up to $350 maximum
Level 2 Pharmacy: 25% up to $450 maximum
Mail Order Pharmacy (90 Day Supply)
Generic (Tier 1) $25 Copay
Preferred (Tier 2) $100 Copay
Non-Preferred (Tier 3) $175 Copay
Preferred Specialty (Tier 4) Level 1 Pharmacy: 25% up to $350 maximum
Level 2 Pharmacy: Not Covered

Level 1 Pharmacies include popular chains such as Target, CVS, Walmart, Giant Eagle and 25,000 other retailers.
Level 2 Pharmacies include popular chains such as Rite Aid and Walgreens. Logon to Anthem.com to locate your preferred pharmacy.

Logon to Anthem.com to locate your preferred pharmacy.

**Deductibles, coinsurance and copayments (medical and prescription drug) accumulate toward the Out-Of-Pocket Maximum.
*Out-of-network retail pharmacy is covered at 50% after the deductible. Out-of-network mail order pharmacy is not covered.

HSA $3500

Services In-Network  Out-of-Network
Calendar Year Deductible (Embedded) $3,500 individual
$7,000 family		 $7,000 individual
$14,000 family
Annual Out-of-Pocket Maximum $6,900 individual
$13,800 family		 $20,700 individual
$41,400 family
Coinsurance 20% after Deductible 50% after Deductible
Primary Care Visits 20% after Deductible 50% after Deductible
Preventive Care Covered at 100% 50% after Deductible
Specialist Visits 20% after Deductible 50% after Deductible
Urgent Care 20% after Deductible 50% after Deductible
Inpatient Hospital 20% after Deductible 50% after Deductible
Outpatient Surgery 20% after Deductible 50% after Deductible
Lab / X-Ray / MRI 20% after Deductible 50% after Deductible
Prescription Drug Coverage – In-Network Retail Pharmacy (30 Day Supply)
Generic (Tier 1) $10 Copay Deductible, then 50%
Preferred (Tier 2) $50 Copay
Non-Preferred (Tier 3) $100 Copay
Preferred Specialty (Tier 4) 25% up to $250 maximum
Mail Order Pharmacy (90 Day Supply)
Generic (Tier 1) $25 Copay Not Covered
Preferred (Tier 2) $125 Copay
Non-Preferred (Tier 3) $250 Copay
Preferred Specialty (Tier 4) 25% up to $250 maximum

***Deductibles, coinsurance and copayments (medical and prescription drug) accumulate toward the Out-Of-Pocket Maximum.

HSA $5000

Services In-Network  Out-of-Network
Calendar Year Deductible (Embedded) $5,000 individual
$10,000 family		 $8,000 individual
$16,000 family
Annual Out-of-Pocket Maximum $6,000 individual
$12,000 family		 $12,000 individual
$24,000 family
Coinsurance 25% after Deductible 50% after Deductible
Primary Care Visits 25% after Deductible 50% after Deductible
Preventive Care Covered at 100% 50% after Deductible
Specialist Visits 25% after Deductible 50% after Deductible
Urgent Care 25% after Deductible 50% after Deductible
Inpatient Hospital 25% after Deductible 50% after Deductible
Outpatient Surgery 25% after Deductible 50% after Deductible
Lab / X-Ray / MRI 25% after Deductible 50% after Deductible
 
Generic (Tier 1) $10 Copay Deductible, then 50%
Preferred (Tier 2) $50 Copay
Non-Preferred (Tier 3) $100 Copay
Preferred Specialty (Tier 4) 25% up to $250 maximum
Mail Order Pharmacy (90 Day Supply)
Generic (Tier 1) $25 Copay Not Covered
Preferred (Tier 2) $125 Copay
Non-Preferred (Tier 3) $250 Copay
Preferred Specialty (Tier 4) 25% up to $250 maximum

***Deductibles, coinsurance and copayments (medical and prescription drug) accumulate toward the Out-Of-Pocket Maximum.

Informational Videos

 

HDHP High Deductible Health Plan

HDHP High Deductible Health Plan

Medical Plan PPO Preferred Provider Organization

Medical Plan PPO Preferred Provider Organization

Medical Plan HDHP with HSA

Medical Plan HDHP with HSA