Page 8 - Asian Box Guide FINAL 9.11

Medical Plans

Anthem Blue Cross Anthem Blue Cross
Plan Name PPO 1 PPO 2
Gold Silver
30/750/20% 3KGD 55/1750/35% 3KH7
Network Name In-Network Non-Network In-Network Non-Network

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $750 $2,000 $1,750 $3,500
- Family $2,250 $4,000 $3,500 $7,000
Out-of-Pocket Maximum
- Individual $7,000 $14,000 $7,700 $15,400
- Family $14,000 $28,000 $15,400 $30,800

Co-Insurance (Plan Pays) 80% 50% 65% 50%
Office Visit Copay
- Preventive Care No Charge 50%; after deduct No Charge 50%; after deduct
- Primary Care Physician $30 Copay 50%; after deduct $55 Copay 50%; after deduct
- Specialist Office Visit $55 Copay 50%; after deduct $80 Copay 50%; after deduct
- Urgent Care $55 Copay 50%; after deduct $80 Copay 50%; after deduct
- Live Health Online No charge for first 3 50%; after deduct No charge for first 3 50%; after deduct
visits; visits;
after $15 Copay after $20 Copay
Hospitalization
- Inpatient 20%; after deduct 50%; after deduct 35%; after deduct 50%; after deduct
- Outpatient 20%; after deduct 50%; after deduct 35%; after deduct 50%; after deduct
Lab and X-Ray
- Diagnostic 20%; after deduct 50%; after deduct 35%; after deduct 50%; after deduct
- Complex 20%; after deduct 50%; after deduct 35%; after deduct 50%; after deduct
Emergency Services $250 Copay then 20% after deduct; $300 Copay then 35% after deduct;
waived if admitted waived if admitted
Chiropractic 50% Not Covered 50% Not Covered

20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $250 Not Covered $300 Not Covered
- Family $500 Not Covered $600 Not Covered
Retail Pharmacy Tier 1a - $5 Retail/ Tier 1a - $5 Retail/
- Generic Formulary Tier 1b -$20 Retail Not Covered Tier 1b -$20 Retail Not Covered
- Brand Name Formulary $40 Copay Not Covered $50 Copay Not Covered
- Non-Formulary $80 Copay Not Covered $90 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A

Mail Order Pharmacy Tier 1a - $13 Retail/ Tier 1a - $13 Retail/
- Generic Formulary Tier 1b -$50 Retail Not Covered Tier 1b -$50 Retail Not Covered
- Brand Name Formulary $120 Copay Not Covered $150 Copay Not Covered
- Non-Formulary $240 Copay Not Covered $270 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

8 Employee Benefits