Page 8 - MMCS Benefit Guide 2019 FINAL

Medical Benefits - All States PPO

Anthem Solution PPO
Plan Features
All States
Network BlueCard Out-of-Network

Health Benefits
Lifetime Maximum Benefit Unlimited
Deductible (Annual)
- Individual $1,500 $4,500
- Family $3,000 $9,000

Co-Insurance (Plan Pays) 80%, after deductible 60%, after deductible
Office Visit Copay
- Primary Care Physician $15 Copay 40%, after deductible
- Specialist Office Visit $15 Copay 40%, after deductible
- Online Visit $10 Copay 40%, after deductible
(Live Health App)
Out-of-Pocket Maximum
- Individual $3,500 $10,500
- Family $7,000 $21,000

Hospitalization
- Inpatient 20%, after deductible 40%, after deductible
- Outpatient 20%, after deductible 40%, after deductible

Lab and X-Ray (Advanced Imaging may vary) 20%, after deductible 40%, after deductible

Emergency Services $150 Copay + 20%, after deductible

Urgent Care $15 Copay 40%, after deductible

Preventive Care 100% 40%, after deductible
Chiropractic $15 Copay 40%, after deductible
Max 30 visits/year
Pharmacy Benefits

Retail Pharmacy
- Tier 1 (a or b) $5 (T1a) /$20 (T1b) 50% coinsurance up to $250
- Tier 2 $40 Copay 50% coinsurance up to $250
- Tier 3 $60 Copay 50% coinsurance up to $250
- Tier 4 30%, max $250 50% coinsurance up to $250
- Supply Limit 30 days 30 days

Mail Order Pharmacy
- Tier 1 (a or b) $12.50 (T1a) /$50 (T1b) Not Covered
- Tier 2 $120 Copay Not Covered
- Tier 3 $180 Copay Not Covered
- Tier 4 30%, max $250 Not Covered
- Supply Limit 90 days N/A

*For complete details, please see the Summary Plan Description on BSwift.

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