Page 6 - Veritax EE Guide 10-1-2019 Non - CA

BENEFITS

MEDICAL INSURANCE

Anthem Anthem Anthem
Gold Silver Bronze
PPO PPO HSA PPO
2
2
2
Network Name Blue Cross PPO Non-Network Blue Cross PPO Non-Network Blue Cross PPO Non-Network
(Prudent Buyer) (Prudent (Prudent
Buyer) Buyer)
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
1
- Individual $0 $2,000 $1,750 $3,500 $6,600 $16,500
- Family $0 $4,000 $3,500 $7,000 $13,200 $33,000
Out-of-Pocket Maximum
- Individual $6,500 $13,000 $7,600 $15,200 $6,600 $16,500
- Family $13,000 $26,000 $15,200 $30,400 $13,200 $33,000

Co-Insurance (You Pay) 30% 50% 40% 50% 0% 50%
Office Visit Copay
- Preventive Care No Charge Ded, 50% No Charge Ded, 50% No Charge Ded, 50%
- Primary Care Physician $20 Copay Ded, 50% $40 Copay Ded, 50% Ded, 0% Ded, 50%
- Specialist Office Visit $50 Copay Ded, 50% $70 Copay Ded, 50% Ded, 0% Ded, 50%
- Urgent Care $50 Copay Ded, 50% $70 Copay Ded, 50% Ded, 0% Ded, 50%
- Telemedicine No Charge 1st 3; N/A No Charge 1st 3; N/A Ded, 0% ($49 N/A
$10 Copay $20 Copay Retail Cost)

Hospitalization
- Inpatient 30% Ded, 50% Ded, 40% Ded, 50% Ded, 0% Ded, 50%
- Outpatient 30% Ded, 50% Ded, 40% Ded, 50% Ded, 0% Ded, 50%
Lab and X-Ray 30% Ded, 50% Ded, 40% Ded, 50% Ded, 0% Ded, 50%

Emergency Services $250 Copay, 30% $250 Copay, Ded, 40% Ded, 0%
Pharmacy Benefits

Retail Pharmacy
- Deductible $250 (Tier 2 & 3) $400 (Tier 2 & 3) Med Deductible
- Tier 1 $20 Copay Not $20 Copay Not Ded, 0% Not
- Tier 2 $40 Copay Covered $50 Copay Covered Ded, 0% Covered
- Tier 3 $80 Copay $90 Copay Ded, 0%
- Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $50 Copay Not Covered $50 Copay Not Covered Ded, 0% Not Covered
- Tier 2 $120 Copay Not Covered $150 Copay Not Covered Ded, 0% Not Covered
- Tier 3 $240 Copay Not Covered $270 Copay Not Covered Ded, 0% Not Covered
- Supply Limit 90 Days N/A 90 Days N/A 90 Days N/A

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