MEDICAL PLAN

Anthem PPO Network

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Plan Rates Subject to Taxes and Admin Fees

COVERAGES

Co-Pays:

. Primary Care — $40 Copay

. Specialist — $40 Copay

. Urgent Care — $40 Copay

. Emergency Room — $350 Copay

Deductible:

. $1,000 Individual / $2,000 Family

Out of Pocket Maximum:

. $9,100 Individual / $18,200 Family

THIS PLAN INCLUDES

. Access to Nationwide PPO Network

. Preventive Care covered at 100%

. Prescription Drug Coverage Included

. Benefit Support and Advocacy

For full coverage details, click MORE DETAILS below

*Pay Period: 1st and 15th of each month

** Plan is offered by Amalgamated Local 426 S.W. Workers Union, and not Anthem BCBS.