Page 5 - NickCo Hospitality_2018 EE Benefits Guide_Hourly Associates_FINAL
P. 5
BENEFITS
Medical Insurance
Anthem Blue Cross
Plan Name Elements HMO
Network Name Select HMO
Health Benefits
Lifetime Maximum Benefit Unlimited
Deductible (Annual)
- Individual $1,500
- Family $1,500 per Member
Co-Insurance (Plan Pays) 100%
Office Visit Copay
- Primary Care Physician $25 Copay
- Specialist Office Visit $50 Copay
- LiveHealth Online $49 Copay
Out-of-Pocket Maximum
- Individual $6,400
- Family $12,800
Hospitalization
- Inpatient Deductible, 30%
- Outpatient Deductible, 30%
Emergency Services $250 Copay, 30%
Ambulance Services (Emergency) $100 Copay
Urgent Care $25 Copay
Preventive Care No Charge
Chiropractic $25 Copay
60 Day Limit
Pharmacy Benefits
Pharmacy Deductible
- Individual $500
- Family $1,500
Retail Pharmacy
- Tier 1a / 1b $5 / $20 Copay
- Tier 2 Deductible, $50 Copay
- Tier 3 Deductible, $65 Copay
- Tier 4 30% Max $250 Copay
- Supply Limit 30 Days
Mail Order Pharmacy
- Tier 1a / 1b $12.50 / $50 Copay
- Tier 2 Deductible, $150 Copay
- Tier 3 Deductible, $195 Copay
- Tier 4 30% Max $250 Copay
- Supply Limit 90 Days
5
