Page 7 - CW Driver Benefit Guide 2019 MAIN

MEDICAL OPTIONS

Option 3: Anthem Blue Cross PPO HIA Medical Plan
The Preferred Provider Organization (PPO) HIA plan with Anthem Blue Cross includes a special Health Incentive Account (HIA).
You can use this account to help you pay for eligible medical and pharmacy benefits. You can earn funds for your HIA by taking
steps that can help you achieve your health potential, such as completing the following programs:
• Future Moms Program: Up to $200 per member and spouse per year
• Online Wellness Toolkit Incentives: Up to $150 per member and spouse per year
• Condition Care Program: Up to $300 per member and spouse per year

As with any PPO plan, you have the freedom to choose your doctor without the requirement of selecting a PCP and you may
self-refer to specialists. You may use an Anthem Blue Cross contracted provider whose negotiated rates provide richer levels of
benefits with claim forms filed by the provider. You may also obtain services using a non-network provider; however, you will be
responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims.

Option 3:
Plan Features Anthem Blue Cross PPO HIA
Medical Plan
Network Name Prudent Buyer PPO Non-Network
Annual HIA Contribution
- Individual $1,000
- Family $2,000

Annual Deductible
- Individual $2,000 $6,000
- Family $4,000 $12,000
Coinsurance (You Pay) 20% 40%
Physician Office Visit $30 Copay Ded, 40%
Out-of-Pocket Maximum
- Individual $5,000 $15,000
- Family $10,000 $30,000
Hospitalization
- Inpatient Ded, 20% Ded, 40% NOTE: Health insurance issuers
- Outpatient Surgery Ded, 20% Ded, 40%
and group health plans are required
Emergency Services Ded, 20% to provide you with an easy-to-
Waived if Admitted understand summary about your
Urgent Care $30 Copay Ded, 40% health plan’s benefits and coverage,
referred to as a Summary of Benefits
Preventive Care $0 Copay Ded, 40% and Coverage (SBC). This guide is

Chiropractic (30 Visits/Year) $30 Copay Ded, 40% designed to help you understand
the medical plan options offered
Prescription Drugs to you by C.W. Driver. Please refer
- Tier 1a/1b $5/15 Copay 40% max $250 Copay to the SBC and carrier contracts
- Tier 2 $40 Copay 40% max $250 Copay found in the Resource Center of the
- Tier 3 $60 Copay 40% max $250 Copay Employee Benefits Portal, provided
- Tier 4 30% Max $250 Copay Not Covered by Kaiser Permanente and Anthem
- Mail Order $12 /$37 | $120 | $180 N/A Blue Cross for additional plan details.
50
50
- Mail Order Supply Limit 90 Days N/A

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