Page 6 - Catasys Benefit Guide 2020-2021
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Medical Benefits
Anthem Blue Cross
Medical Benefits HSA 1500
Network Prudent Buyer PPO Non-Network
Lifetime Maximum Unlimited
Deductible (Annual)
- Individual $1,500 / $2,700 per member $4,500
- Family $3,000 $9,000
Co-Insurance (Plan Pays) 80% 60%
Office Visit Copay
- Primary Care Physician 80% 60%
- Specialist Office Visit 80% 60%
Lab and X-Ray 80%/80% 60%
Complex Radiology 80% 60%
(CT, MRI, PET) - Prior
Authorization Required
Out-of-Pocket Maximum
- Individual $3,000 $9,000
- Family $6,000 $18,000
Hospitalization 80% 60% (Limited to $1,000 Per Day)
Emergency Services 80%
Urgent Care 80% 60%
Preventive Care 100% 60%
Chiropractic 80% 60%
30 Visits/Benefit Period
Acupuncture 80% 60%
20 Visits/Benefit Period
Pharmacy Benefits
Retail Pharmacy
- Tier 1a/1b $5 or $15 Copay 60%
- Tier 2 $40 Copay 60%
- Tier 3 $60 Copay 60%
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $12.50 or $37.50 Copay Not Covered
- Tier 2 $120 Copay Not Covered
- Tier 3 $180 Copay Not Covered
- Supply Limit 90 Days N/A
Deductible - Ind./Family Combined with Medical Deductible N/A
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