Page 5 - Guide
P. 5
PPO Plan 2017 Beneits Enrollment
HDHP Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $750 $1,500 $3,000 $6,000
Family $1,500 $3,000 $6,000 $12,000
Out of Pocket Maximum (includes deductibles)
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000 $14,000 $7,000 $14,000
Common Services
Preventive Care No charge $50 copay 100% no deductible 70% after deductible
Primary Care Visits $25 copay 60% after deductible 90% after deductible 70% after deductible
Specialist Visits $40 copay 60% after deductible 90% after deductible 70% after deductible
Inpatient Services 80% after deductible 60% after deductible 90% after deductible 70% after deductible
Outpatient Services 80% after deductible 60% after deductible 90% after deductible 70% after deductible
Emergency Room 100% after $100 copay 100% after $100 copay 90% after deductible 70% after deductible
Urgent Care 100% after $35 copay 100% after $35 copay 90% after deductible 70% after deductible
Pharmacy Coverage—Mandatory Generic
Deductible
Retail Supply Limit 30 days
Tier 1 $10 60% after deductible 90% after deductible 70% after deductible
Tier 2 $35 60% after deductible 90% after deductible 70% after deductible
Tier 3 $60 60% after deductible 90% after deductible 70% after deductible
Mail Order Supply Limit 90 days
Tier 1 $25 Not covered 90% after deductible Not covered
Tier 2 $88 Not covered 90% after deductible Not covered
Tier 3 $150 Not covered 90% after deductible Not covered
Coverage Tier PPO Semi-Monthly Premium Cost HDHP Semi-Monthly Premium Cost
Standard Rate Discounted Rate Standard Rate Discounted Rate
Employee $80.32 $65.82 $59.73 $48.95
Employee + Spouse $203.69 $167.29 $149.36 $122.67
Employee + Child(ren) $165.10 $135.40 $121.24 $99.43
Family $278.24 $228.74 $203.32 $167.15
Tobacco Cessation
Anthem Blue Cross and Blue Shield of Colorado is partnering with National Jewish
Health to offer Anthem BCBS QuitLine from 6 a.m. to 11 p.m., Monday through
Sunday. With this line, you can reach dedicated coaches to reduce stress, cravings,
and weight gain. Nicotine patches, lozenges, gum, and educational materials are also
available. The tobacco cessation program can be utilized by calling 855.891.9988. Be
sure to have your ID card when you call.
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HDHP Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $750 $1,500 $3,000 $6,000
Family $1,500 $3,000 $6,000 $12,000
Out of Pocket Maximum (includes deductibles)
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000 $14,000 $7,000 $14,000
Common Services
Preventive Care No charge $50 copay 100% no deductible 70% after deductible
Primary Care Visits $25 copay 60% after deductible 90% after deductible 70% after deductible
Specialist Visits $40 copay 60% after deductible 90% after deductible 70% after deductible
Inpatient Services 80% after deductible 60% after deductible 90% after deductible 70% after deductible
Outpatient Services 80% after deductible 60% after deductible 90% after deductible 70% after deductible
Emergency Room 100% after $100 copay 100% after $100 copay 90% after deductible 70% after deductible
Urgent Care 100% after $35 copay 100% after $35 copay 90% after deductible 70% after deductible
Pharmacy Coverage—Mandatory Generic
Deductible
Retail Supply Limit 30 days
Tier 1 $10 60% after deductible 90% after deductible 70% after deductible
Tier 2 $35 60% after deductible 90% after deductible 70% after deductible
Tier 3 $60 60% after deductible 90% after deductible 70% after deductible
Mail Order Supply Limit 90 days
Tier 1 $25 Not covered 90% after deductible Not covered
Tier 2 $88 Not covered 90% after deductible Not covered
Tier 3 $150 Not covered 90% after deductible Not covered
Coverage Tier PPO Semi-Monthly Premium Cost HDHP Semi-Monthly Premium Cost
Standard Rate Discounted Rate Standard Rate Discounted Rate
Employee $80.32 $65.82 $59.73 $48.95
Employee + Spouse $203.69 $167.29 $149.36 $122.67
Employee + Child(ren) $165.10 $135.40 $121.24 $99.43
Family $278.24 $228.74 $203.32 $167.15
Tobacco Cessation
Anthem Blue Cross and Blue Shield of Colorado is partnering with National Jewish
Health to offer Anthem BCBS QuitLine from 6 a.m. to 11 p.m., Monday through
Sunday. With this line, you can reach dedicated coaches to reduce stress, cravings,
and weight gain. Nicotine patches, lozenges, gum, and educational materials are also
available. The tobacco cessation program can be utilized by calling 855.891.9988. Be
sure to have your ID card when you call.
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