Page 6 - Oremor Benefits Flipbook

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
Lifetime Maximum Benefit Unlimited Unlimited

Deductible (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 Deductible, 60%
- Specialist Office Visit $50 Copay $15 Copay Deductible, 60%
Out-of-Pocket Maximum
- Individual $4,000 $3,000 $10,000
- Family Limit $8,000 $6,000 $20,000

Hospitalization
- Inpatient Deductible, 20% Deductible, 10% Deductible, 40%
Max $600 Benefit/Day
- Outpatient Deductible, 20% Deductible, 10% Deductible, 40%
Max $600 Benefit/Day
Emergency Services $150 Copay, 20% $100 Copay, 10%
Urgent Care $20 Copay Deductible, 10% Deductible, 40%

Preventive Care No Charge No Charge Not Covered
Physical Therapy / Physical $50 Copay $15 Copay Deductible, 40%
Medicine & Occupational Max $25 Benefit/Visit
Therapy / Speech Therapy
Max 24 Visits/Year Max 24 Visits/Year
Pharmacy Benefits
Specialty Out-of-Pocket Maximum
- Individual $7,150 N/A N/A
- Family $14,300 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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