Medical

Jim Ellis offers two medical plans through Anthem for the 2019-2020 plan year.  Both plans offer in-network and out-of-network coverage, but An HMO with in-network coverage only, a POS plan with both in and out-of-network coverage, but member costs are substantial when going out-of-network.  You are highly encouraged to obtain all services from in-network providers.

Employees enrolled with an annual earnings below $50,000 receive an additional employer contribution towards medical coverage in compliance with the Affordable Care Act (or ACA).  Jim Ellis funds an additional employer contribution towards your medical coverage and to meet the definition of affordable coverage.  The full funding amount will apply towards the Anthem Blue Essential Open Access POS plan. 

 
Important Plan Information - Both Plans
Both Anthem plans include out-of-network coverage, but member costs are substantial. We highly encourage you to obtain all services from in-network providers. How to locate in-network providers:
  • Access Anthem.com and Click “Find a Doctor.” Search by plan.
  • Click “Select a State” and select Georgia. Select “Medical (Employer-Sponsored) for type of plan.
  • Select “Blue Open Access POS (Select Network)” as the plan / network and follow search instructions. (The networks are the same for both plans.)
 
Important Diagnostic Outpatient Lab Information - Both Plans
In order to receive full coverage for your lab work, you must visit LabCorp. Quest labs is considered out-of-network. If lab work is performed in the physician’s office, it is subject to the deductible for the Blue Essential Open Access POS Plan.
 
Anthem Blue Essential Open Access POS
  • You are not required to select a Primary Care Physician or receive referrals to Specialists for coverage to apply.
  • Physician office visits are covered at 100% after a copay. However, surgery performed in a physician’s office is subject to the deductible.
  • Please note: This plan does not include coverage for allergy testing, chiropractic care, or therapy (physical, occupation, or speech)
  • Preventive care is covered at 100% in-network.
  • For x-ray and advanced imaging services (MRI, CAT, PET) at an in-network freestanding radiology center, you pay coinsurance but no deductible.
  • This plan has a $500 pharmacy deductible applicable to medications that are not included on Tier 1.
  • Hearing aid coverage is limited to children up to age 19 only.
 
Anthem Blue Open Access POS (Buy-Up)
  • This is the buy-up plan option. The plan includes a lower deductible and enhanced benefits.
  • You are not required to select a Primary Care Physician or receive referrals to Specialists for coverage to apply.
  • Physician office visits are covered at 100% after a copay. Surgery performed in a physician’s office is subject to the deductible.
  • This plan does not include a pharmacy deductible.

 

Additional Benefits for Blue Essential Open Access POS Participants

 

Jim Ellis provides the following additional benefits to Blue Essential Open Access POS plan members to supplement your medical plan in the event of an unexpected illness or accident.

  • $2,000 Critical Illness benefit for diagnosis of heart attack, stroke, internal cancer, kidney failure, major organ transplant, carcinoma in situ (25%), coronary artery bypass surgery (25%), coma, paralysis, deafness, blindness, benign brain tumor, and occupational HIV.
  • Accident coverage according to the certificate schedule.

Benefits are provided for employees, spouses, and children covered on the Blue Essential Open Access POS plans.

 

Important Documents

Blue Essential Open Access
In-Network
Blue Essential Open Access
Out-of-Network
Blue Open Access (Buy-Up)
In-Network
Blue Open Access (Buy-Up)
Out-of-Network
Calendar Year Deductible
     
Member
$5,000 $15,000 $2,500 $7,500
Family
$10,000 $30,000 $7,500 $15,000
Coinsurance
Plan Pays 70% Plan Pays 50% Plan Pays 70% Plan Pays 50%
Calendar Year Out-of-Pocket Limit
Member
$7,900 $23,700 $7,900 $23,700
Family
$15,800 $47,400 $15,800 $47,400
Preventive Care
No Charge 50% After Deductible No Charge 50% After Deductible
Doctor Office Visits
Primary Care Physician (PCP)
$30 50% After Deductible $30 50% After Deductible
Specialist
$60 50% After Deductible $60 50% After Deductible
Outpatient Diagnostic Lab & X-Ray
No Charge at LabCorp No Charge at LabCorp
In Office / Center
30% After Deductible 50% After Deductible $30 \ $60 - No Deductible 50% After Deductible
Freestanding Center
Lab: 30% After Deductible X-Ray: 30% - No Deductible 50% After Deductible Lab: 100% X-Ray: 30% 50% After Deductible
Outpatient Hospital
30% After Deductible 50% After Deductible 30% After Deductible 50% After Deductible
Advanced Diagnostics & Imaging
In Office / Center
30% After Deductible 50% After Deductible 30% After Deductible 50% After Deductible
Freestanding Center
30% - No Deductible 50% After Deductible 30% - No Deductible 50% After Deductible
Outpatient Hospital
30% After Deductible 50% After Deductible $500 + 30% After Deductible 50% After Deductible
Outpatient Surgery
Freestanding Center
$150 + 30% - No Deductible 50% After Deductible $150 + 30% - No Deductible 50% After Deductible
Outpatient Hospital
30% After Deductible 50% After Deductible $500 + 30% After Deductible 50% After Deductible
Inpatient Hospitalization
$500 + 30% After Deductible 50% After Deductible $500 + 30% After Deductible 50% After Deductible
Emergency Care
$350 + 30% $350 + 30% Can be subject to balance billing as determined by the provider $350 + 30% $350 + 30% Can be subject to balance billing as determined by the provider
Urgent Care
$75 Copay 50% After Deductible $75 Copay 50% After Deductible
Allergy Testing
Not Covered Not Covered $30 or $60 copay 50% After Deductible
Chiropractic Care
Not Covered Not Covered $60 - 20 visit max combined 50% After Deductible - 20 visit max
Therapy (physical, occupational, speech)
Not Covered Not Covered $60 - 20 visit max combined 50% After Deductible - 20 visit max

Prescription Drug Benefits


Ingenio is Anthem’s pharmacy vendor, and now is a great time to review the covered medications and learn how you may be able to reduce your costs. Ingenio Rx also provides 24/7 access via phone for prescription questions, orders, and refills.


The Essential Drug List is Anthem / Ingenio’s list of covered prescription medications for your medical plan. Please access the complete list on the Resources page or www.anthem.com. About the drug formulary:

  • Includes a retail benefit (up to 90-day supply) and a home delivery benefit
  • Tier 1 includes medications that typically fall into the generic category
  • Tier 2 typically includes preferred brand medications
  • Tier 3 includes non-preferred higher cost brand medications
  • Tier 4 includes Ingenio’s specialty brand and generic medications (covers up to a 30 day supply for both retail and home delivery)

 

Review the prescription drug list carefully to ensure your medications are covered and to confirm your cost.  The drug list is a document of commonly prescribed medications sorted by cost levels, or tiers.  The medications are noted if step therapy, supply limits, specialty, and / or prior authorization is required.  For more information, visit www.anthem.com.

Blue Essential Open Access POS Blue Open Access POS (Buy-Up)
Pharmacy Deductible
Up to 31 day supply
$500 per person | $1,000 Family Not Applicable
Tier 1
Retail and Home Delivery: $15 Copay Pharmacy Deductible Does Not Apply Retail and Home Delivery: $15 Copay
Tier 2
Retail: $40 Copay After Pharmacy Deductible Home Delivery: $80 Copay After Deductible Retail: $35 Copay Home Delivery: $70 Copay
Tier 3
Retail: $75 Copay After Pharmacy Deductible Home Delivery: $225 Copay After Deductible Retail: $60 Copay Home Delivery: $180 Copay
Tier 4
Retail and Home Delivery: 25% coinsurance up to $350 after pharmacy deductible Retail and Home Delivery: 25% coinsurance up to $350

Finding a Participating Provider


Access www.anthem.com and click "Find a Doctor."  Search by plan.

  • Click “Select a State” and select Georgia. Select “Medical (Employer-Sponsored) for type of plan.
  • Select “Blue Open Access POS (Select Network)” as the plan / network and follow search instructions.  The networks are the same for both plans.

Wellness


Employee health and wellness continues to be a priority for Jim Ellis.  The Jim Ellis Wellness Program is designed to help you improve your health with incentives when you complete simple tasks.  When you comply with the requirements by the due date, you avoid potential surcharges.

  • Biometric screening: In order to avoid the $25 per month surcharge, you must complete the screening within 60 days of your benefits effective date.
  • Non-tobacco affidavit or active participation in tobacco cessation program for tobacco users: To avoid the separate $25 per month surcharge, you must complete the non-tobacco affidavit or be an active participant in tobacco cessation by the deadline.

More information is available on the Wellness page of this website.  Additionally, the non-tobacco affidavit is available in the Resources section.

Telemedicine


The medical plans include a telemedicine benefit which allows you to speak to a participating doctor from home or work through your smartphone, tablet or computer 24 hours a day / 7 days a week, at no cost to you

Consider this convenient benefit for non-complex medical conditions. such as:

  • Allergies
  • Colds / influenza
  • Headaches / migraines
  • Sprains / strains
  • Infections: ear, sinus, respiratory, urinary tract, etc.
  • Minor burns
  • And more

As a telemedicine member, all family members are required to complete a Personal Health History Disclosure (which can be found on the Resources page) prior to your first consultation.  This Disclosure is forwarded to an on-call physician when you call 1800MD.  The physician reviews and returns your call to complete the consultation, make a diagnosis, issue prescriptions (if necessary) and refer you to a primary or specialist physician or hospital (if necessary).  We encourage you to call 1800MD or go online to complete your medical history prior to needing services: 800-530-8666 or www.1800md.com

Earning Rewards through Anthem


The Anthem reward program can be accessed through www.bcbsga.com.  Once you are logged in, go to the Health & Wellness section.  Select Get My Rewards. Below are a few of the things you can do to earn rewards.

  1. Health Assessment $50: Gives you a snapshot of your health, so you know what's going well and if there are any at-risk areas you should work on.
  2. Tobacco Free ($50): Confirm you are tobacco free or join a Health Action Plan.
  3. Preventice Care ($100): Get an annual wellness exam and flu shot, and you will earn $100.

You can earn up to $200 in rewards per calendar year.  When you complete your first healthy activity, you will receive a Health Rewasrds card.  It's a reloadable card you can use anywhere major credit cards are accepted.  As you earn more rewards, they'll be automatically deposited into your rewards account and available to spend using you card.