Page 6 - Oremor EE Benefits Guide 01-19.pub

Benefits

Medical Insurance

EBA&M (Anthem Blue Cross) EBA&M (Anthem Blue Cross)
Plan Name Network PPO PPO
Network Name Network Network Non‐Network
Health Benefits
Life me Maximum Benefit Unlimited Unlimited

Deduc ble (Annual)
‐ Individual $100 $250
‐ Family Limit $200 $500
Co‐Insurance (Plan Pays) 80% 90% 60%
Office Visit Copay
‐ LiveHealth Online $10 Copay $10 Copay N/A
‐ Primary Care Physician $20 Copay $15 Copay Deduc ble, 60%
‐ Specialist Office Visit $50 Copay $15 Copay Deduc ble, 60%
Out‐of‐Pocket Maximum
‐ Individual $4,000 $3,000 $10,000
‐ Family Limit $8,000 $6,000 $20,000

Hospitaliza on
‐ Inpa ent Deduc ble, 20% Deduc ble, 10% Deduc ble, 40%
Max $600 Benefit/Day
‐ Outpa ent Deduc ble, 20% Deduc ble, 10% Deduc ble, 40%
Max $600 Benefit/Day
Emergency Services $150 Copay, 20% $100 Copay, 10%
Urgent Care $20 Copay Deduc ble, 10% Deduc ble, 40%

Preven ve Care No Charge No Charge Not Covered
Physical Therapy / Physical $50 Copay $15 Copay Deduc ble, 40%
Medicine & Occupa onal Max $25 Benefit/Visit
Therapy / Speech Therapy Max 24 Visits/Year
Max 24 Visits/Year
Pharmacy Benefits
Specialty Out‐of‐Pocket Maximum
‐ Individual $7,900 N/A N/A
‐ Family $15,800 N/A N/A

Retail Pharmacy
‐ Generic Formulary $10 Copay $10 Copay Not Covered
‐ Brand Name Formulary $30 Copay $25 Copay Not Covered
‐ Non‐Formulary 50% to $150 Max $50 Copay Not Covered
‐ Specialty 30% to $500 Max N/A Not Covered
‐ Supply Limit 30 Days 30 Days N/A
Mail Order Pharmacy
‐ Generic Formulary $20 Copay $20 Copay Not Covered
‐ Brand Name Formulary $60 Copay $50 Copay Not Covered
‐ Non‐Formulary 50% Max $300 $100 Copay Not Covered
‐ Specialty 30% Max $500 (30 Day Supply) N/A Not Covered
‐ Supply Limit 90 Days 90 Days N/A

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