Page 6 - TCR Benefit Guide 2017 - sent 9.12.17

Benefits

Medical Insurance

Anthem Select Value Anthem Select Anthem
Plan Name Deductible HMO Classic HMO PPO
Network Name Select HMO Network Select HMO Network Prudent Buyer PPO Non-Network
Health Benefits

Deductible (Annual)
- Individual $500/Member None $750 $2,250
- Family $500/Member None $2,250 $6,750
Co-Insurance (You Pay) 20% N/A 20% 40%
Office Visit Copay
- Primary Care Physician $20 Copay $35 Copay $30 Copay Ded, 40%
- Specialist Office Visit $40 Copay $45 Copay $30 Copay Ded, 40%

Out-of-Pocket Maximum
- Individual $3,000 $2,500 $5,000 $15,000
- Family $6,000 $5,000 $10,000 $30,000
Hospitalization
- Inpatient Ded, 20% $750 Copay Ded, 20% Ded, 40% ($1,000
Benefit Max)
- Outpatient Ded, 20% $375 Copay Ded, 20% Ded, 40% ($350
Benefit Max)

Lab and X-Ray No Charge No Charge Ded, 20% Ded, 40% ($800
- Complex Imaging $100 (Freestanding $100 (Freestanding Benefit Max)
Radiology Center) Radiology Center and
Ded, 20% (Outpatient Outpatient Hospital)
Hospital)
Emergency Services Ded, $150, 20% $100 Copay Ded, $150, 20%
Urgent Care $20 Copay $35 Copay $30 Copay Ded, 40%

Preventive Care No Charge No Charge No Charge Ded, 40%
Mental Health
- Inpatient Ded, 20% $750 Copay Ded, 20% Ded, 40% ($1,000
Benefit Max)
- Outpatient $20 Copay $35 Copay $30 Copay Ded, 40%
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family None None None None
Retail Pharmacy
- Tier 1a/1b $5/$20 Copay $5/$15 Copay $5/$20 Copay 50%
- Tier 2 $40 Copay $30 Copay $30 Copay 50%
- Tier 3 $75 Copay $50 Copay $50 Copay 50%
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1a/1b $12.50/$50 Copay $12.50/$37.50 Copay $12.50/$50 Copay Not Covered
- Tier 2 $120 Copay $90 Copay $90 Copay Not Covered
- Tier 3 $225 Copay $150 Copay $150 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
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