For Active Employees and non-Medicare Retirees Effective July 1, 2024

Please note: There are some exceptions to the tables below; please see the Benefits Summary for a more complete explanation of health coverage.

Health Coverage

Type of Visit or Test	Copay Amount
Office visit with a primary care doctor who participates in the Anthem network	$20
Office visit with a specialist who participates in the Anthem network	$40
Visit to a participating walk-in clinic (PDF)	$25
Visit to an emergency room (copay is waived if admitted to in-patient status)	$300

• Office visit copay is waived for preventive visits
• No referral required by the insurance plan for visits to specialist or walk-in clinic

Out-of-Pocket Expense	Individual		Family
	In-Network	Out-of-Network	In-Network	Out-of-Network
Calendar year deductible	$600	$3,000	$1,200	$6,000
Coinsurance rate - participating provider	10%	40%	10%	40%
Annual maximum out-of-pocket expense (deductible + coinsurance + healthÌýcopay)	$2,000	$5,000	$4,000	$10,000

Prescription Coverage

Medication Category	Up to 30-Day Supply Copay Amount Per Prescription	Up to 90-Day Supply Copay Amount Per Prescription
Generics	$10	$15
Preferred brand-name	$30	$45
Non-preferred brand name	$45	$70
Specialty	25% coinsurance up to $150	25% coinsurance up to $225
Lifestyle	$50	$75

To Register for Capital Rx -

1.) VisitÌý

2.) Fill in your personal information and clickÌýVALIDATE

3.) Complete credentials form and clickÌýCREATE ACCOUNT

4.) Check your email and locate the verification code sent from Capital Rx

5.) Enter the code provided to validate your email address

Registration is complete!ÌýYou can now login using your credentials established during registration

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