Page 6 - Community Health Systems Guide 2018-FINAL v2
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Medical Benefits
Anthem Blue Cross
Plan Name HMO
Network Full Network (Blue Cross HMO (CACare) - Large Group)
Health Benefits
Lifetime Maximum Unlimited
Deductible (Annual) None
Office Visit Copay
- Primary Care Physician $10 Copay
- Specialist Office Visit $30 Copay
- Online Visit Not covered
Out-of-Pocket Maximum
- Individual $2,000
- Family $4,000
Hospitalization
- Inpatient $250 per admission
- Outpatient $125 copay per admission
Lab and X-Ray No charge
Emergency Services $100 Copay per visit
Urgent Care $10 Copay
Preventive Care No Charge
Chiropractic / Acupuncture $10 Copay
Coverage for In-Network Provider is limited to 60 visit
limit per benefit period for Physical, Occupational and
Speech Therapy combined. Chiropractic visits count to‐
wards your physical and occupational therapy limit.
Pharmacy Benefits
Pharmacy Deductible None
Retail Pharmacy
- Tier 1A / Tier 1B $5 / $15 Copay
- Tier 2 $30 Copay
- Tier 3 $50 Copay
- Tier 4 30% up to $250
- Supply Limit 30 Days
Mail Order Pharmacy
- Tier 1A / Tier 1B $12.50 / $37.50 Copay
- Tier 2 $90 Copay
- Tier 3 $150 Copay
- Tier 4 30% up to $250
- Supply Limit 90 Days
Video – Learn About Medical Plan Terms
Medical plan terms, such as deductibles, copays, coinsurance and out-of-pocket maximums, can sometimes
be confusing. For a quick video that shows how these work, visit http://video.burnhambenefits.com/terms.
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