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Medical Plan Choices | All Locations 6

Medical Plans Available in All Locations

Plan Anthem Blue Cross Anthem Blue Cross
Features Premier PPO Lumenos HSA
In-Network 1 Out-of-Network 1 In-Network 1 Out-of-Network 1
Annual HSA N/A Individual: $3,450
Contribution Limit Family: $6,900

Annual Deductible Individual: $500 Deductible must be paid in full before copays
Family: $1,000 and coinsurance apply; ABC Company
funds 100% of the deductible
Individual: $2,700
Family: $5,400
Annual Out-of-Pocket Individual: $2,500 Individual: $6,500 Individual: $5,000 Individual: $10,000
Maximum Family: $5,000 Family: $13,000 Family: $10,000 Family: $20,000

Lifetime Maximum Benefits Unlimited Unlimited
Medical Services
Doctor’s Office Visits $20 copay Covered at 70% Covered at 80% Covered at 60%
Specialist: $40 copay
Preventive Care Covered at 100%; Covered at 70% Covered at 100%; Covered at 60%
deductible waived deductible waived

Physical Therapy Covered at 90% Covered at 70% Covered at 80% Covered at 60%
Alternative Care
Chiropractic $20 copay 2 Covered at 70% 2 Covered at 80% 2 Covered at 60% 2

Acupuncture $20 copay 3 Covered at 70% 3 Covered at 80% 3 Covered at 60% 3
Prescription Drugs
Retail Pharmacy Tier 1: $10 copay Covered at 50% of Tier 1: $10 copay Covered at 60%
(30-Day Supply) Tier 2: $25 copay maximum allowed Tier 2: $40 copay
Tier 3: $45 copay amount after copay Tier 3: $60 copay
Tier 4: Covered at 70%; Tier 4: Covered at 70%;
$250 copay max $250 copay max

Mail Order Tier 1: $25 copay Not covered Tier 1: $25 copay Not covered
(90-Day Supply) 4 Tier 2: $75 copay Tier 2: $120 copay
Tier 3: $135 copay Tier 3: $180 copay
Tier 4: Covered at 70%; Tier 4: Covered at 70%;
$250 copay max $250 copay max
Hospital Services
Room & Board/Surgeon’s Covered at 90% Covered at 70%; Covered at 80% Covered at 60%
Fees/Maternity Delivery limited to $1,000/day

Emergency Care Covered at 90% after $100 copay; Covered at 80%
waived if admitted
Mental Health/
Substance Abuse Services
Outpatient $20 copay Covered at 70% Covered at 80% Covered at 60%

Inpatient Covered at 90% Covered at 70%; Covered at 80% Covered at 60%
limited to $1,000/day
1 Payable at the negotiated fee rate and subject to deductible.
2 Limited to 30 visits per calendar year for both in-network and out-of-network combined.
3 Limited to 20 visits per calendar year.
4 Limited to 30-day supply for Tier 4 prescriptions.