Page 7 - Cylance EE Guide 01-19 All Employees

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name PPO HSA
Network Name Prudent Buyer PPO Non-Network Prudent Buyer PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $350 $1,500 $4,500
- Family $700 $3,000 $9,000

Co-Insurance (Plan Pays) 90% 70% 80% 60%
Office Visit Copay
- Primary Care Physician $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Specialist Office Visit $30 Copay Deductible, 30% Deductible, 20% Deductible, 40%
Out-of-Pocket Maximum
- Individual $4,000 $7,500 $4,500 $9,000
- Family $8,000 $15,000 $9,000 $18,000

Hospitalization
- Inpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Complex Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services Deductible, $150 Copay, 10% Deductible, 20%

Urgent Care $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
Preventive Care No Charge Deductible, 30% No Charge Deductible, 40%
Chiropractic $10 Copay Deductible, 30% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible $0 $0 Health Deductible Applies
Retail Pharmacy
- Tier 1 $10 Copay Copay +50% $10 Copay Copay +50%
- Tier 2 $30 Copay Copay +50% $30 Copay Copay +50%
- Tier 3 $50 Copay Copay +50% $50 Copay Copay +50%
- Tier 4 30% Max $350 Copay Copay +50% 30% Max $350 Copay Copay +50%
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $25 Copay Not Covered $25 Copay Not Covered
- Tier 2 $90 Copay Not Covered $90 Copay Not Covered
- Tier 3 $150 Copay Not Covered $150 Copay Not Covered
- Tier 4 30% Max $350 Copay* Not Covered 30% Max $350 Copay* Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
*Tier 4 mail order supply limit is 30 days.
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