Page 9 - Asian Box Guide FINAL 9.11

Medical Plans

Anthem Blue Cross
Plan Name PPO 3
Bronze 65/4600/40% 3KJ9
Network Name In-Network Non-Network
Lifetime Maximum Unlimited

Deductible (Annual)
- Individual $4,600 $9,200
- Family $9,200 $18,400
Out-of-Pocket Maximum
- Individual $7,900 $15,800
- Family $15,800 $31,600

Co-Insurance (Plan Pays) 60% 50%
Office Visit Copay
- Preventive Care No Charge 50%; after deduct
- Primary Care Physician $65 Copay 50%; after deduct
- Specialist Office Visit $85 Copay 50%; after deduct
- Urgent Care 40%; after deduct 50%; after deduct
- Live Health Online No charge for first 3 visits; 50%; after deduct
after $20 Copay

Hospitalization
- Inpatient 40%; after deduct 50%; after deduct
- Outpatient 40%; after deduct 50%; after deduct

Lab and X-Ray
- Diagnostic 40%; after deduct 50%; after deduct
- Complex 40%; after deduct 50%; after deduct

Emergency Services 50%; after deductible

Chiropractic 50% Not Covered
20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual Combined with medical Not Covered
- Family Combined with medical Not Covered
Retail Pharmacy Tier 1a - $10 Retail
- Generic Formulary Tier 1b -$20 Retail Not Covered
- Brand Name Formulary $60 Copay Not Covered
- Non-Formulary $90 Copay Not Covered
- Supply Limit 30 Days N/A

Mail Order Pharmacy Tier 1a - $25 Retail
- Generic Formulary Tier 1b -$50 Retail Not Covered
- Brand Name Formulary $180 Copay Not Covered
- Non-Formulary $270 Copay Not Covered
- Supply Limit 90 Days N/A

Employee Benefits 9