Page 5 - ENCO Benefits Guide 01-20 Florida_FINAL

BENEFITS

MEDICAL INSURANCE

ANTHEM BLUE CROSS
PLAN NAME PPO
Network Name Prudent Buyer PPO Non-Network
or Blue Card
Health Benefits
Deductible (Annual)
- Individual $250 $2,000
- Family $750 $4,000

Co-Insurance (Plan Pays) 90% 50%
Office Visit Copay
- Primary Care Physician $15 Copay Deductible, 50%
- Specialist Office Visit $30 Copay Deductible, 50%

Out-of-Pocket Maximum
- Individual $4,000 $8,000
- Family $8,000 $16,000

Hospitalization
- Inpatient Deductible, 10% Deductible, 50%
- Outpatient Deductible, 10% Deductible, 50%
Emergency Services Deductible, $200 Copay, 10%

Urgent Care $30 Copay Deductible, 50%
Preventive Care 100% Deductible, 50%

Chiropractic 50% Not Covered
20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Tier 1a/1b $10 Copay Not Covered
- Tier 2 $35 Copay Not Covered
- Tier 3 $70 Copay Not Covered
- Tier 4 30% Max $250 Copay Not Covered
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $25 Copay Not Covered
- Tier 2 $105 Copay Not Covered
- Tier 3 $210 Copay Not Covered
- Tier 4 (30 days only) 30% Max $250 Copay Not Covered
- Supply Limit 90 Days N/A

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