Page 7 - 2015 CBRY Enrollment Guide

ASARCO

2015 Medical Plan Options

Option 1—HRA Plan Option 2—PPO Plan
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
Individual $1,500 $3,000 $750 $1,500
Family $3,000 $6,000 $1,500 $3,000
Medical Out-of-Pocket Maximum (includes annual deductible)
Individual $3,000 $6,000 $2,250 $4,500
Family $6,000 $12,000 $4,500 $9,000
Lifetime Maximum Unlimited Unlimited
Hospital
Inpatient 80% after ded 70% after ded 80% after ded 70% after ded
Outpatient 80% after ded 70% after ded 80% after ded 70% after ded
Emergency Room $150 copay *, plus ded then 80% $150 copay *, plus ded then 80%
Physician Visits and Ancillary Services
Preventive Care 100% No coverage 100% No coverage
Primary Care Physician (Family or General $20 copay 70% after ded 80% after ded 70% after ded
Practitioner, Internist, Pediatrician, OB/GYN,
Nurse Practitioner, Physician Assistant and
Mental Health/Substance Abuse providers)
Specialist Visits $50 copay 70% after ded 80% after ded 70% after ded
Chiropractic Care ($1,500 calendar year $50 copay 70% after ded 80% after ded 70% after ded
maximum and $15,000 lifetime maximum)
Urgent Care $50 copay 70% after ded $50 copay 70% after ded
Outpatient Lab Services, X-Ray, Radiology 80% after ded 70% after ded 80% after ded 70% after ded
Inpatient Lab Services, X-Ray, Radiology 80% after ded 70% after ded 80% after ded 70% after ded
Physical, Occupational, and Speech Therapy 80% after ded 70% after ded 80% after ded 70% after ded
Mental Health and Substance Abuse
Inpatient 80% after ded 70% after ded 80% after ded 70% after ded
Outpatient 80% after ded 70% after ded 80% after ded 70% after ded

* Emergency Room copay waived if admitted.

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