Page 6 - Iron Chef EE Guide 12-17

Benefits

Medical Insurance

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name 5900 HMO 1500 HMO 1000 35/20 PPO
Network Name Select HMO Select HMO Blue Cross PPO Non-Network
(Prudent Buyer) -
Large Group
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $5,900 $1,500 $1,000 $3,000
- Family $5,900/Member $1,500/Member $3,000 $9,000

Co-Insurance (Plan Pays) 70% 70% 80% 60%
Office Visit Copay
- Primary Care Physician $35 Copay $25 Copay $35 Copay Deductible, 40%
- Specialist Office Visit $70 Copay $50 Copay $35 Copay Deductible, 40%

Out-of-Pocket Maximum
- Individual $6,400 $6,400 $5,000 $15,000
- Family $12,800 $12,800 $10,000 $30,000
Hospitalization
- Inpatient Ded, 30% Ded, 30% Ded, 20% Ded, 40%
- Outpatient Ded, 30% Ded, 30% Ded, 20% Ded, 40%

Emergency Services Ded, $250 Copay, 30% Ded, $250 Copay, 30% Ded, $150 Copay, 20%
Urgent Care $35 Copay $20 Copay $35 Copay Ded, 40%
Preventive Care No Charge No Charge No Charge Ded, 40%

Chiropractic $35 Copay $25 Copay $35 Copay Deductible, 40%
60 Day Limit 60 Day Limit 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $500 $500 $0 $0
- Family $1,500 $1,500 $0 $0
Retail Pharmacy
- Tier 1a/1b $5/$20 Copay $5/$20 Copay $5/$20 Copay 50% Max $250
- Tier 2 Ded, $50 Copay Ded, $50 Copay $30 Copay 50% Max $250
- Tier 3 Ded, $65 Copay Ded, $65 Copay $50 Copay 50% Max $250
- Tier 4 Ded, 30% Max $250 Ded, 30% Max $250 30% Max $250 50% Max $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
50
50
- Tier 1a/1b $12 /50 Copay $12 /50 Copay $12 /50 Copay Not Covered
- Tier 2 Ded, $150 Copay Ded, $150 Copay $90 Copay Not Covered
- Tier 3 Ded, $195 Copay Ded, $195 Copay $150 Copay Not Covered
- Tier 4 Ded, 30% Max $250 Ded, 30% Max $250 30% Max $250 Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

6