Medical
Medical coverage helps protect you and your family by covering a range of healthcare services. Preventive care—like annual physicals, flu shots, and routine screenings—is covered at 100% when you visit in-network providers, helping you stay healthy and catch potential issues early. Merced County offers four medical plan options, including two EPO plans and two PPO plans. The Anthem 500 and Anthem 1500 plans are EPO (Exclusive Provider Organization) plans. With these plans, services are covered only when you see providers in the plan’s network. The one exception is emergency care, which is covered even if it happens outside the network. Other services from out-of-network providers are not covered. Merced County also offers two Anthem High Deductible Health Plans (HDHPs)—one that comes with a Health Savings Account (HSA) and one that does not. The HDHP plans are PPO (Preferred Provider Organization) plans and use the Prudent Buyer network. This means you have the flexibility to see both in-network and out-of-network providers, though preventive care is only covered when you use in-network providers. The main differences between the plans come down to how much you pay each paycheck and what you pay when you receive 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.
Anthem 500 (EPO)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay per visit
Retail Rx (Per 30-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Non-Preferred Brand
$30 copay
Mail-Order Rx (Per 90-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$45 copay
Bi-Weekly Plan Cost
Employee Only: $91.71
Employee and Spouse: $501.36
Employee and Child(ren): $263.15
Employee and Family: $657.23
Anthem 1500 (EPO)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$45 copay per visit, deductible does not apply
Specialist Visit
$45 copay per visit, deductible does not apply
Urgent Care
$45 copay per visit, deductible does not apply
Emergency Room
$100 copay per visit, then No Charge after deductible is met **
Retail RX (Up to 30-Day Supply)
Generic
$20
Preferred Brand
$40
Non-Preferred Brand
$60
Mail-Order RX (Up to 90-Day Supply)
Generic
$30
Preferred Brand
$50
Non-Preferred Brand
$70
*copay waived if admitted
Bi-Weekly Plan Cost
Employee Only: $0.00
Employee and Spouse: $282.52
Employee and Child(ren): $141.99
Employee and Family: $456.27
Anthem HDHP with HSA
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,700/$3,900
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0 copay
Primary Care Visit
$25 copay after deductible
Specialist Visit
$25 after deductible
Urgent Care
10% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Per 30-Day Supply)
Preventive- Generic
$0 copay
Generic
$15 copay after deductible
Preferred Brand
$25 copay after deductible
Non-Preferred Brand
$35 copay after deductible
Mail-Order Rx (Per 90-Day Supply)
Preventive- Generic
$0 copay
Generic
$30 copay after deductible
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$70 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$2,600/$7,800
Out-of-Pocket Max (Individual/Family)
$8,000/$16,000
Preventive Care
Not Covered
Primary Care Visit
20% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
30% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Per 30-Day Supply)
Preventive- Generic
30% coinsurance after deductible
Generic
30% coinsurance after deductible
Preferred Brand
30% coinsurance after deductible
Non-Preferred Brand
30% coinsurance after deductible
Mail-Order Rx (Per 90-Day Supply)
Preventive- Generic
Not Covered
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Bi-Weekly Plan Cost
Employee Only: $0.00
Employee and Spouse: $285.43
Employee and Child(ren): $144.90
Employee and Family: $459.66
Anthem HDHP without HSA
Benefit Highlights
In-Network
Deductible (Single)
$1,700
Out-of-Pocket Max (Single)
$4,000
Preventive Care
$0 copay
Primary Care Visit
$25 copay after deductible
Specialist Visit
$25 copay after deductible
Urgent Care
10% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Per 30-Day Supply)
Preventive- Generic
$0 copay after deductible
Generic
$15 copay after deductible
Preferred Brand
$25 copay after deductible
Non-Preferred Brand
$35 copay after deductible
Mail-Order Rx (Per 90-Day Supply)
Preventive- Generic
Not Covered
Generic
$30 copay after deductible
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$70 copay after deductible
Out-of-Network
Deductible (Single)
$2,600
Out-of-Pocket Max (Single)
$8,000
Preventive Care
Not Covered
Primary Care Visit
30% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
10% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Per 30-Day Supply)
Preventive- Generic
30% coinsurance after deductible
Generic
30% coinsurance after deductible
Preferred Brand
30% coinsurance after deductible
Non-Preferred Brand
30% coinsurance after deductible
Mail-Order Rx (Per 90-Day Supply)
Preventive- Generic
Not Covered
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Bi-Weekly Plan Cost
Employee Only: $0.00