Page 8 - Aspiration Partners Employee Benefits Guide – National

Anthem Blue Cross Anthem Blue Cross
Plan Name Classic PPO 750 Solution PPO 5500
Prudent Buyer Prudent Buyer
Network Name PPO Non-Network PPO Non-Network

Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual $750 $2,250 $5,500 $16,500
- Family $2,250 $6,750 $11,000 $33,000
Out-of-Pocket Maximum
- Individual $5,000 $15,000 $7,350 $22,050
- Family $10,000 $30,000 $14,700 $44,100
Coinsurance (Plan Pays) 80% 60% 70% 50%
Office Visit Copay
- Preventive Care No Charge Deductible, 40% No Charge Deductible, 50%
- Primary Care Physician $30 Copay Deductible, 40% $30 Copay Deductible, 50%
- Specialist $50 Copay Deductible, 40% $50 Copay Deductible, 50%
- Urgent Care $30 Copay Deductible, 40% $30 Copay Deductible, 50%
Hospitalization
- Inpatient Deductible, 20% Deductible, 40%* Deductible, 30% Deductible, 50%
- Outpatient Surgery Deductible, 20% Deductible, 40%* Deductible, 30% Deductible, 50%
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40% Deductible, 30% Deductible, 50%
- Complex Deductible, 20% Deductible, 40%* Deductible, 30% Deductible, 50%
Emergency Services
Deductible, $150 Copay, 20% Deductible, $150 Copay, 30%

Chiropractic $30 Copay Deductible, 40% $30 Copay Deductible, 50%
Max 30 Visits/Plan Year Max 30 Visits/ Plan Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Generic (1a/1b) $5 / $20 50% to $250 $5 / $20 50% to $250
- Brand Name Formulary $30 50% to $250 $40 50% to $250
- Brand Non-Formulary $50 50% to $250 $60 50% to $250
- Supply Limit 30 days 30 days 30 days 30 days
Mail Order Pharmacy
- Generic (1a/1b) $12.50 / $50 Not covered $12.50 / $50 Not covered
- Brand Name Formulary $90 Not covered $120 Not covered
- Brand Non-Formulary $150 Not covered $180 Not covered
- Supply Limit 90 days n/a 90 days n/a

*Out-of-Network limits apply