Page 6 - Milani EE Benefits Booklet.pub

[EMPLOYEE BENEFITS]

MEDICAL INSURANCE

ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME HMO SELECT NETWORK HMO VIVITY NETWORK

Network Name Select HMO Vivity HMO

HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Single $0 $0
- Per Member $0 $0
- Per Family $0 $0
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay
- LiveHealth Online Telemedicine Retail Rate $20 Copay
Out-of-Pocket Maximum
- Single $2,500 $2,500
- Per Member N/A N/A
- Per Family $5,000 $5,000
Hospitalization
- Inpatient $500 Copay per Admission $500 Copay per Admission
- Outpatient $250 Copay per Admission $250 Copay per Admission
Lab and X-Ray
- Diagnostic No Charge No Charge
- Advanced Imaging $100 Copay per Test $100 Copay per Test
Emergency Services $100 Copay $100 Copay
Urgent Care $20 Copay $20 Copay
Preventive Care No Charge No Charge
Chiropractic $20 Copay $20 Copay
60-Day Limit per Benefit Period 60-Day Limit per Benefit Period
PHARMACY BENEFITS

Pharmacy Deductible
- Individual $0 $0
- Family $0 $0

Retail Pharmacy
- Tier 1a / 1b (30 Day Supply) $5 / $15 Copay $5 / $15 Copay
- Tier 2 (30 Day Supply) $30 Copay $30 Copay
- Tier 3 (30 Day Supply) $50 Copay $50 Copay
- Tier 4 (30 Day Supply) 30% Max $250 Copay 30% Max $250 Copay
Mail Order Pharmacy
- Tier 1a / 1b (90 Day Supply) $12 / $37 Copay $12 / $37 Copay
50
50
50
50
- Tier 2 (90 Day Supply) $90 Copay $90 Copay
- Tier 3 (90 Day Supply) $150 Copay $150 Copay
- Tier 4 (30 Day Supply) 30% Max $250 Copay 30% Max $250 Copay

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