Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
PIH Health Plan
Plan Information
Plan Name: PIH Health Plan
Policy Number: Luminare # PH0000
Anthem # L11807
Effective Date: 01/01/2025
Provider Network: PIH Health/Anthem BlueCross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$20 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (Up to 90-Day Supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
25% coinsurance up to $250
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$45 copay
Urgent Care
$30 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – CarelonRx (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – CarelonRx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
Not covered
Plan Documents
Contact Information
PIH Health CDHP
Plan Information
Plan Name: PIH Health CHDP
Policy Number: Luminare # PH0000
Anthem # L11807
Effective Date: 01/01/2025
Provider Network: PIH Health/Anthem BlueCross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Individual in a Family/Family)
$1,650/$3,300/$3,300
Out-of-Pocket Max (Individual/Family)
$3,300/$6,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
20% after deductible
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (Up to 90-Day Supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
25% coinsurance up to $250
Tier 3: Out-of-Network Providers
Deductible (Individual /Family)
$4,000/$8,00
Out-of-Pocket Max (Individual/Family)
$10,000/$20,000
Preventive Care
Not covered
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
25% coinsurance + $20 copay
Preferred Brand
25% coinsurance + $20 copay
Non-Preferred Brand
25% coinsurance + $20 copay
Specialty
25% coinsurance + $20 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Individual in a Family/Family)
$2,500/$3,300/$5,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
20% after deductible
Retail Rx – CarelonRx (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – CarelonRx (Up to 90-Day Supply)
Generic
$40 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
25% coinsurance up to $250
Plan Documents
Contact Information
PIH Health EPO
Plan Information
Plan Name: PIH Health EPO
Policy Number: Luminare # PH0000
Anthem # L11807
Effective Date: 01/01/2025
Provider Network: PIH Health/Anthem BlueCross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
Tier 1: PIH Health Providers
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$20 copay
Emergency Room
$150 copay (waived if admitted)
Retail Rx – PIH Health Retail (Up to 30-Day Supply)
Generic
$6 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
25% coinsurance up to $250
Retail Rx – PIH Health Retail (Up to 90-Day Supply)
Generic
$12 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Specialty
25% coinsurance up to $250
Tier 2: Anthem BlueCross Preferred Providers
Deductible (Individual/Family)
$1,000/$1,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
$30 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$30 copay (deductible waived)
Emergency Room
$150 copay (waived if admitted)
Retail Rx – CarelonRx (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$100 copay
Specialty
25% coinsurance up to $250
Mail-Order Rx – CarelonRx (Up to 90-Day Supply)
Generic
$40 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$200 copay
Specialty
Not covered