Page 7 - Career Group Guide 2020 - Temporary Out of State

Medical Plan Highlights

Anthem Blue Cross
Plan Name Elements Choice PPO

Blue Cross PPO (Prudent Buyer)
Network Name Large Group Non-Network
Health Benefits
Lifetime Maximum Unlimited

Deductible (Annual)
- Individual $6,500 $19,500
- Family $13,000 $39,000
Out-of-Pocket Maximum
- Individual $7,350 $22,050
- Family $14,700 $44,100

Co-Insurance (Plan Pays) 100% 50%

Office Visit Copay
- Preventive Care No Charge Deductible, 50%
- Primary Care Physician $35 Copay* Deductible, 50%
- Specialist Office Visit $35 Copay* Deductible, 50%
- Urgent Care Deductible, 0% Deductible, 50%
- Telemedicine $35 Copay* Deductible, 50%

Hospitalization
- Inpatient Deductible, 0% Deductible, 50%
- Outpatient Deductible, 0% Deductible, 50%
Lab and X-Ray
- Diagnostic Deductible, 0% Deductible, 50%
- Complex Deductible, 0% Deductible, 50%
Emergency Services Deductible, 0%

Chiropractic $35 Copay* Deductible, 50%

30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible $500/$1,500 $500/$1,500
Retail Pharmacy
- Generic Formulary $5/$20 Copay 50% to $250
- Brand Name Formulary Deductible, $50 Copay Deductible, 50% to $250
- Non-Formulary Deductible, $65 Copay Deductible, 50% to $250
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $12.50/$50 Copay Not Covered
- Brand Name Formulary Deductible, $150 Copay Not Covered
- Non-Formulary Deductible, $195 Copay Not Covered
- Supply Limit 90 Days N/A

*$35 copay per visit for the first 3 visits, then 0% coinsurance after deductible is met.

Employee Benefits 7