Page 4 - Marvin - Final Brochure w_ Compliance notices 2021

Marvin Engineering Co
2021–22 Employee Benefits Brochure

Medical Plans

Anthem Blue Cross PPO (Prudent Buyer)

In-Network Out-of-Network

Deductible:
Individual $100 $200
Family $300 $600

Out-of-Pocket Limit (per calendar year)
Individual $500 $1,500
Family $1,500 $4,500

Hospital Services:
Inpatient 10% coinsurance 30% coinsurance
Outpatient Surgery 10% coinsurance 30% coinsurance max $500/day
Emergency Room 10% coinsurance 30% coinsurance
(copay waived if admitted)

Physician Services:
Office Visit (PCP/Specialist) 10% coinsurance 30% coinsurance
Pre-Natal Maternity 10% coinsurance 30% coinsurance
Diagnostic Lab & X-Ray 10% coinsurance 30% coinsurance
Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance
Urgent Care 10% coinsurance 30% coinsurance
Acupuncture See benefit summary See benefit summary
Chiropractor See benefit summary See benefit summary

Routine Care: Screening/immunization
Preventative Checkups 10% coinsurance Not Covered

Prescription Drugs:
Generic Drugs - Tier 1 $5 retail/$5 Mail order See benefit summary
Preferred Brand- Tier 2 $10 retail/$5 Mail order See benefit summary
Non-Preferred Brand- Tier 3 $10 retail/$5 Mail order See benefit summary
Specialty Drugs- Tier 4 $10 retail/$5 Mail order See benefit summary
DME (Durable Medical Equipment) 10% coinsurance 30% coinsurance

Retail Rx: Up to a 30 day supply from a retail pharmacy
Mail Oder Rx: 31-90 day supply from Express Scripts Pharmacy

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