Page 8 - 2019 Sharks Benefits V6.1

Medical Plan Comparison—PPO

Benefits at a Glance
PPO/Blue Card
Plan Features Anthem Blue Cross
In Network Benefits Non-Network Benefits
Lifetime Maximum Benefit
Per Member Unlimited Unlimited
Co-Insurance
Inpatient 10% 30%
Outpatient 10% 30%
Annual Deductible
Individual $250 $250
Family $250/member; 3 member max. $250/member; 3 members max.
Annual Out of Pocket Maximum
Individual $2,000 $6,000
Family $2,000/member; 3 members $6,000/member; 3 members
max. max.
Physician Services
Office Visit $15/visit (deductible waived) 30%
Preventative Care (limited 10% (deductible waived) 30% (deductible waived)
to one exam each year)
Well Child Care $15/visit (deductible waived) 30% up to $20/exam
Laboratory and X-Ray 10% 30%
Services
Allergy Injection $15/visit (deductible waived) Not Covered
Chiropractic Care 10%
Hospital Services
Emergency Room $100 (waived if admitted) then $100 (waived if admitted) then
10% 10%
Room and Board $500 (waived if admitted) then 30%
10%
Outpatient Surgery 10% 30%
Laboratory and X-Ray 10% 30%
Services
Mental and Nervous
Inpatient (limitations apply) 10% 30%
Outpatient (limitations
apply) 10% 30%
Prescription Drugs
Generic/Brand
$10/$20/$40 $10/$20/$40
Name/Formulary
Mail Order $40/$40/$80 Co-pay plus 50%
Generated/Brand $10/$40/$80
Name/Formulary 90 days Co-Insurance

See Benefit Summaries for complete details.
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