Page 8 - Benefit Guide 2019.2020 - Final

[EMPLOYEE BENEFITS]

MEDICAL INSURANCE

ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME HSA PPO PPO

Network Name Prudent Buyer or Non-Network Prudent Buyer or Non-Network
Blue Card (NonCA) Blue Card (NonCA)
HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Single $2,000 $6,000 $1,000 $3,000
- Per Member $2,700 $6,000 N/A N/A
- Per Family $4,000 $12,000 $3,000 $9,000
Co-Insurance (Plan Pays) 80% 60% 80% 60%
Office Visit Copay
- Primary Care Physician Deductible, 20% Deductible, 40% $35 Copay Deductible, 40%
- Specialist Office Visit Deductible, 20% Deductible, 40% $35 Copay Deductible, 40%
- Telemedicine Deductible, 20% Deductible, 40% $10 Copay Deductible, 40%
Out-of-Pocket Maximum
- Single $3,000 $9,000 $5,000 $15,000
- Per Member $3,000 $9,000 N/A N/A
- Per Family $6,000 $18,000 $10,000 $30,000

Hospitalization
- Inpatient Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
- Advanced Imaging Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
Emergency Services Deductible, 20% Deductible, $150 Copay, 20%
Urgent Care Deductible, 20% Deductible, 40% $35 Copay Deductible, 40%
Preventive Care No Charge Deductible, 40% No Charge Deductible, 40%
Chiropractic Deductible, 20% Deductible, 40% $35 Copay Deductible, 40%
30 Visits/Year 30 Visits/Year

Pediatric Dental Not Covered Not Covered
PHARMACY BENEFITS
Pharmacy Deductible
- Individual Health Deductible Health Deductible $0 $0
- Family Health Deductible Health Deductible $0 $0
Retail Pharmacy
- Tier 1a / 1b (30 Day Supply) $5 / $15 Copay 40% Max $250 Copay $5 / $20 Copay 50% Max $250 Copay
- Tier 2 (30 Day Supply) $40 Copay 40% Max $250 Copay $30 Copay 50% Max $250 Copay
- Tier 3 (30 Day Supply) $60 Copay 40% Max $250 Copay $50 Copay 50% Max $250 Copay
- Tier 4 (30 Day Supply) 30% Max $250 Copay 40% Max $250 Copay 30% Max $250 Copay 50% Max $250 Copay

Mail Order Pharmacy
50
- Tier 1a / 1b (90 Day Supply) $12 / $37 Copay Not Covered $12 / $50 Copay Not Covered
50
50
- Tier 2 (90 Day Supply) $120 Copay Not Covered $90 Copay Not Covered
- Tier 3 (90 Day Supply) $180 Copay Not Covered $150 Copay Not Covered
- Tier 4 (30 Day Supply) 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered
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