Page 6 - Cylance EE Guide 01-17 National

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name PPO HSA
Network Name Prudent Buyer PPO Non-Network Prudent Buyer PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $250 $250 $1,500 $4,500
- Family $500 $500 $2,600/Member $4,500/Member
$3,000/Family $9,000/Family

Co-Insurance (Plan Pays) 90% 70% 80% 60%
Office Visit Copay
- Primary Care Physician $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Specialist Office Visit $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
Out-of-Pocket Maximum
- Individual $2,500 $4,500 $3,000 $9,000
- Family $5,000 $9,000 $3,000/Member $9,000/Member
$6,000/Family $18,000/Family
Hospitalization
- Inpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
- Complex Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services Deductible, $100 Copay, 10% Deductible, 20%
Urgent Care $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
Preventive Care No Charge Deductible, 30% No Charge Deductible, 40%

Chiropractic $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible $0 $0 Health Deductible Applies

Retail Pharmacy
- Tier 1 $10 Copay 50% $10 Copay 40%
- Tier 2 $25 Copay 50% $40 Copay 40%
- Tier 3 $45 Copay 50% $60 Copay 40%
- Tier 4 30% Max $250 Copay 50% 30% Max $250 Copay 40%
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $25 Copay Not Covered $25 Copay Not Covered
- Tier 2 $75 Copay Not Covered $120 Copay Not Covered
- Tier 3 $135 Copay Not Covered $180 Copay Not Covered
- Tier 4 30% Max $250 Copay* Not Covered 30% Max $250 Copay* Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

*Tier 4 mail order supply limit is 30 days.
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