Page 13 - HM Benefits Guide 2019 National

Medical Plans

Anthem Blue Cross
PPO (High)
Network Name PPO (Prudent Buyer) Non-Network
Health Benefits
Lifetime Maximum Unlimited
Annual Deductible
• Individual $500 $1,500
• Family $1,500 $4,500
Out-of-Pocket Maximum
• Individual $3,500 $10,500
• Family $7,000 $21,500
Coinsurance (You Pay) 20% 40%
Physician Office Visit
• Preventive Care No Charge Deductible, 40%
• PCP $20 Copay Deductible, 40%
• Specialist $40 Copay Deductible, 40%
• Urgent Care $20 Copay Deductible, 40%
• Telemedicine $10 Copay N/A
Hospitalization
• Inpatient Deductible, 20% Deductible, 40%*
• Outpatient Surgery Deductible, 20% Deductible, 40%*
Emergency Services $150 Copay, 20%
Chiropractic $20 Copay Deductible, 40%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
• Tier 1a / 1b $5 / $15 Copay 50% Max $250
• Tier 2 $30 Copay 50% Max $250
• Tier 3 $50 Copay 50% Max $250
• Supply Limit 30 Days 30 Days
Mail Order Pharmacy
• Tier 1a / 1b $12 / $37 Copay Not Covered
50
50
• Tier 2 $90 Copay Not Covered
• Tier 3 $150 Copay Not Covered
• Supply Limit 90 Days N/A

Specialty
• Tier 4 30% Max $250 50% Max $250
• Supply Limit 30 Days (Retail / M.O.) 30 Days (Retail Only)
*Limitations apply. See SBC for details.

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