Page 5 - ASMS Employee Guide 2017

Medical Insurance

ANTHEM BLUE CROSS ANTHEM BLUE CROSS
Select Value HMO 30/40/30%

(Limited Network)
Lumenos HSA PPO 2000 10/30
Plan Features Value HMO 30/40/30%
(Full Network)

1
HMO Network Prudent Buyer Network Non-Network
Lifetime Maximum Unlimited Unlimited
Annual Deductible
- Individual None $2,000 $2,000
- Family None $4,000 $4,000
Co-Insurance (Plan Pays) 100% 90% after Deductible 70% after Deductible
Office Visit Copay
- Primary Care Physician $30 Copay 10%; after Ded 30%; after Ded
- Specialist Office Visit $40 Copay 10%; after Ded 30%; after Ded
Out of Pocket Maximum
- Individual $5,000 $3,000 $6,000
- Family $10,000 $6,000 $12,000
Hospitalization
2
- Inpatient 30% coinsurance 10%; after Ded 30%; after Ded
3
- Outpatient 30% coinsurance 10%; after Ded 30%; after Ded
Lab and X-Ray
3
- Lab (Freestanding Lab / Hospital) No Charge / 30% 10%; after Ded 30%; after Ded
- X-Ray (Freestanding Center / Hospital) No charge / 30% 10%; after Ded 30%; after Ded 3
4
- Complex (MRI, CT, SPECT, PET, MRA) $100 Copay 10%; after Ded 30%; after Ded
Emergency Services $200 Copay 10%; after Deductible
Urgent Care $30 10%; after Ded 30%; after Ded

Preventive Care Covered in full Covered in full 30%; after Ded
Chiropractic $30 copay 10%; after Ded 30%; after Ded
Limits apply Max 30 Visits/Year
Mental Health & Substance Abuse
2
- Inpatient 30% coinsurance 10%; after Ded 30%; after Ded
1
- Outpatient $30 Copay 10%; after Ded 30%; after Ded
Pharmacy Deductible None
$150
Applies to Prescriptions Only (Medical Plan Deductible Above Applies)
Prescription Drugs - Retail
- Generic Formulary $15 Copay $10 Copay 30%; after Ded
- Brand Name Formulary $40 Copay $40 Copay 30%; after Ded
- Non-Formulary $60 Copay $60 Copay 30%; after Ded
- Supply Limit 30 Days 30 Days 30%; after Ded
Prescription Drugs - Mail Order
- Generic Formulary $37.50 Copay $25 Copay Not Covered
- Brand Name Formulary $120 Copay $120 Copay Not Covered
- Non-Formulary $180 Copay $180 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A
1
Certain Covered Services have maximum visit and/or day limits per year. The member is responsible for all costs over the plan maximums.
Please review full summary for out-of-network benefit limitations.
2 Coverage for Out-of-Network Provider is limited to $1,000 maximum per day.
3
Coverage for Out-of-Network Provider is limited to $350 maximum per visit.
4
Coverage for Out-of-Network Provider is limited to $800 maximum per test.

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