MMC Benefits Handbook
The Medical Plan Options at a Glance
The chart below outlines some important Plan features and coverage information that distinguish the three available Anthem BlueCross BlueShield (Anthem BCBS) medical plan options. Additional information is provided throughout this section of the Benefits Handbook including the "Detailed List of Covered Services."
NOTE: The plan features described below (deductibles, coinsurance, etc.) for the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN Non-Tiered)) are reflected under in-network. Out-of-network services are not covered under the Anthem BCBS Narrow Network, except for urgent and emergency care. Additional information is provided throughout this section of the Benefits Handbook including the "Detailed List of Covered Services."
Plan feature
$400 Deductible Plan1
$1,500 Deductible Plan1
$2,850 Deductible Plan1
Annual Deductible
In-network: Employee: $400
Family2: $8003
Out-of-network: Employee: $2,500
Family2: $5,0003
In-network:
Employee: $1,500
Family2: $3,0004
Out-of-network:
Employee: $3,000
Family2: $6,0004
In-network:
Employee: $2,850
Family2: $5,7003
Out-of-network:
Employee: $5,700
Family2: $11,4003
Out-of-Pocket Maximum
(including deductible)
In-network:
Employee: $2,200
Family2: $4,4003
Out-of-network:
Employee: $4,400
Family2: $8,8003
In-network:
Employee: $3,000
Family2: $6,0004
Out-of-network:
Employee: $6,000
Family2: $12,0004
In-network:
Employee: $5,500
Family2: $11,0003
Out-of-network:
Employee: $11,000
Family2: $22,0003
Plan Coinsurance
In-network: 80% coinsurance after deductible
Out-of-network: 60% coinsurance after deductible (Out-of-network benefits are based on reasonable and customary charges)
In-network: 70% coinsurance after deductible Out-of-network: 50% coinsurance after deductible (Out-of-network benefits are based on reasonable and customary charges)
Physician office visits
Preventive Visit
In-network:
Covered at 100%
Out-of-network:
60% coinsurance after deductible
In-network:
Covered at 100%
Out-of-network:
60% coinsurance after deductible
In-network:
Covered at 100%
Out-of-network:
50% coinsurance after deductible
Primary Care Physician (PCP)/Specialist Visit
In-network:
$20 copay5
Out-of-network:
60% coinsurance of R&C after deductible
Copay amounts do not apply to the deductible.
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance of R&C after deductible
In-network:
70% coinsurance after deductible
Out-of-network:
50% coinsurance of R&C after deductible
Specialist Visit
In-network:
$40 copay5
Out-of-network:
60% coinsurance of R&C after deductible
Copay amounts do not apply to the deductible.
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance of R&C after deductible
In-network:
70% coinsurance after deductible
Out-of-network:
50% coinsurance of R&C after deductible
Hospital Facility
Inpatient
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance after deductible
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance after deductible
In-network:
70% coinsurance after deductible
Out-of-network:
50% coinsurance after deductible
Outpatient
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance after deductible
In-network:
80% coinsurance after deductible
Out-of-network:
60% coinsurance after deductible
In-network:
70% coinsurance after deductible
Out-of-network:
50% coinsurance after deductible
Emergency Room (waived if admitted)
In and Out-of-network:
$150 copay per visit, 80% coinsurance after deductible
In and Out-of-network:
80% coinsurance after deductible
In and Out-of-network:
70% coinsurance after deductible
Prescription drugs
There is a CVS Caremark® Retail Pharmacy Network for 30-day supply (acute) and CVS Caremark® Retail and CVS Caremark® Mail Order for 90-day supply (maintenance) Prescription drugs.
Retail Prescriptions
(30-day supply)
  • Generic
$10 copay5,6 (These amounts do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$30 copay5,6 (These amounts to do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$60 copay5,6 (These amounts do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
CVS Caremark® Retail and CVS Caremark® Maintenance Choice Program Mail-order Prescriptions7
(90-day supply)
  • Generic
$25 copay5,6 (These amounts do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$75 copay5,6 (These amounts do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$150 copay5,6 (These amounts do not apply to the deductible)
80% coinsurance after deductible
70% coinsurance after deductible
Prescription Drug Programs
There are prescription drug programs available as part of the medical plan options. For information on Rx Savings Solutions, PrudentRx, Transform Diabetes® Care, WW Digital Program and Hello Heart, refer to the "Prescription Drug Programs" section.
Contact Information for Third Party Administrator options:
Contact for Medical Service:
Anthem BCBS (Claims Administrator)
P.O. Box 105187
Atlanta, GA 30348-5187
Anthem BCBS Customer Service: +1 855 570 1150
Website: www.anthem.com
Contact for Prescription Service:
CVS Caremark® (Prescription Drug Benefits Manager)
Phone: +1 844 449 0362
Website (for members): www.caremark.com
CVS Caremark® Group #: 21CW
Marsh McLennan does not administer claims under this plan. For medical claims, the Claims Administrators' decisions are final and binding. For prescription drug claims, the Prescription Drug Benefits Manager's decisions are final and binding.
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except Employee-Only.
3 Not "True" Family: For the $400 and $2,850 Deductible Plans, if more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a family member meets his or her individual deductible, benefits begin for that family member only, but not for the other family members. When the family deductible is met, benefits begin for every covered family member whether or not they have met their own individual deductibles. The family deductible can only be met by a combination of family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for that family member only, but not for the other family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for every covered family member whether or not they have met their own individual out-of-pocket maximums. The family out-of-pocket maximum can only be met by a combination of family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: The $1,500 Deductible Plan does not require that you or a covered eligible family member meet the "individual" deductible in order to satisfy the family deductible. If more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is satisfied. The family deductible may be met by one family member or a combination of family members. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is satisfied for any one covered family member when the family out-of-pocket maximum is satisfied. The family out-of-pocket maximum may be met by one family member or a combination of family members.
5 Office visit copays and prescriptions do not apply toward the annual deductible.
6 A mandatory program, the PrudentRx prescription drug program, for eligible specialty medications for complex conditions on the PrudentRx Drug List will apply. If you do not speak with PrudentRx, do not enroll in any copay assistance as required by a manufacturer, or do not choose to participate in the PrudentRx program, i.e. opt out, you'll be responsible for paying the 30% coinsurance cost for each specialty prescription medication, and the costs will NOT count towards your deductible or out-of-pocket maximum. The PrudentRx Drug List is available at www.caremark.com. For drugs not on the PrudentRx Drug List, standard mail order copayments will apply. The PrudentRx Program applies only to the $400 Deductible Plan. For more information, refer to "Are there mandatory discount or copay assistance programs applicable for specialty prescription drugs?" and "Prescription Drug Programs."
7 In addition to mail order, you will be able to fill a 90-day supply of your maintenance medications at a CVS Caremark® retail pharmacy, at the same cost as you would through the mail order program. For all maintenance medications, after the first three fills, you must fill a 90-day supply either at a CVS Caremark® retail pharmacy or through the CVS Caremark® Maintenance Choice Mail Order program otherwise, the maintenance medication will not be covered, you will pay 100% of the full cost for all subsequent fills, and the cost does not accumulate towards the deductible and out-of-pocket maximum.