MEDICAL & PRESCRIPTION

DG3 North America, Inc. seeks to provide the best possible medical benefits at a reasonable cost. Employees are provided with a medical plan option thought Anthem that includes prescription drug coverage.

ANTHEM | MEDICAL & PHARMACY

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Annual Deductible: For non-preventive care there is an annual deductible that must be met. The annual deductible is $6,200 for Individual coverage and $12,400 for Family Coverage when you use in-network providers.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, co-payments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs, for the remainder of the year.

For 2025 the deductible will increase to $6,200 for singles and to $12,400 for family. To lessen the impact on employees, DG3 is offering a Health Reimbursement Arrangement (HRA). Once you meet the deductible of $2,500 for single or $5,000 for employee plus one or more dependents you can submit eligible claims ($3,500 for single or $7,000 for employee plus one or more dependents) to be reimbursed by the Health Reimbursement Account.

Claims forms can be downloaded under Resources or by contacting Human Resources. As a reminder, to submit for reimbursement you must complete the claim form provided and submit, along with your corresponding explanation of benefits, to the email address on the form.

In-Network Advantage (National Blue Card PPO Network)

When you use an in-network provider, the percentage you pay out-of-pocket will be based on a negotiated fee, which is usually lower than the actual charges. If you use a provider who is outside of the network, you may be responsible for paying for the difference between the Usual, Customary and Reasonable (UCR) charges and what the provider charges. You also may need to submit claim forms

How To Find a Provider at www.anthem.com Click “Find a Doctor/Find Care” – Guest – Enter Type of Care, State, Plan Type (Medical(Employer Sponsored)) – Network (National PPO (BlueCare PPO Basic))

Essential Formulary Link: https://www.anthem.com/oh/pharmacy-information/drug-list-formulary

Resources

Anthem Summary of Benefits & Coverage

Anthem Sydney Health App

Anthem Member Flyer

Service Support Flyer

Rewards Flyer

Preventive Drug List

Essential Formulary

HRA Claim Form

Mail Order Pharmacy Flyer

ANTHEM HDHP	In Network Providers National PPO (BlueCard PPO)	Out of Network Providers
Calendar Year Deductible: Single/Family	$6,200 / $12,400	$18,600 / $37,200
Coinsurance	0% after deductible	30% after deductible
Maximum Out of Pocket Limit: Single / Family (Includes the deductible)	$6,900 / $13,800	$20,700 / $41,400
Office Visit	0% after deductible	30% after deductible
Specialist Office Visit	0% after deductible	30% after deductible
Surgical Services	0% after deductible	30% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA	0% after deductible	30% after deductible
Urgent Care Centers	0% after deductible	30% after deductible
Emergency Medical Care	0% after deductible	30% after deductible
In-Patient Hospital Services	0% after deductible	30% after deductible
Out-Patient Hospital Services	0% after deductible	30% after deductible
Prescription Drugs: Medical Deductible applies first, then;
Retail (30 day supply)	0%-30% after deductible	50% after deductible
Mail Order (90 day supply)	0%-30% after deductible	50% after deductible