Page 11 - Incipio EE Guide 01-19 Non-CA Bi-Weekly

BENEFITS

Medical Insurance

ANTHEM
PLAN NAME PPO 500 DEDUCTIBLE
NETWORK NAME Prudent Buyer PPO Non-Network*
Health Benefits

Lifetime Maximum Unlimited
Deductible (Annual)
- Individual $500 $1,500
- Family $1,500 $4,500
Co-Insurance (You Pay) 10% 30%
Office Visit Copay
- Primary Care Physician $20 Copay Deductible, 30%
- Specialist Office Visit $20 Copay Deductible, 30%
- Virtual Visit $10 Copay Deductible, 30%
Out-of-Pocket Maximum
- Individual $3,500 $10,500
- Family $7,000 $21,000
Hospitalization
- Inpatient Deductible, 10% Deductible, 30%
- Outpatient Surgery Deductible, 10% Deductible, 30%

Lab and X-Ray
- Diagnostic Deductible, 10% Deductible, 30%
- Advanced Deductible, 10% Deductible, 30%
Emergency Services Deductible, $150 Copay, 10%
Urgent Care $20 Copay Deductible, 30%
Preventive Care No Charge Deductible, 30%

Chiropractic $20 Copay Deductible, 30%
30 Visits/Year
Pharmacy Benefits
Tier 2, 3, & 4 Deductible None None
Retail Pharmacy
- Tier 1a/1b $5/$15 Copay 50% up to $250
- Tier 2 $30 Copay 50% up to $250
- Tier 3 $50 Copay 50% up to $250
- Tier 4 30% Max $250 Copay 50% up to $250
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
50
50
- Tier 1a/1b $12 /$37 Copay Not Covered
- Tier 2 $90 Copay Not Covered
- Tier 3 $150 Copay Not Covered
- Tier 4 30% Max $250 Copay Not Covered
- Supply Limit 90 Days N/A
*Limitations apply. See SBC for details. Please refer to the Summary of Benefits and Coverages (SBCs) provided by
Anthem for additional plan details. These documents are located on HR Connection.
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