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Benefits

Medical Insurance

Anthem Blue Cross HDHP PPO w/ HSA

Network Non Network
Health Benefits

Lifetime Maximum Benefit Unlimited * HDHP HSA Deductible:
Under the family deductible,
Annual Maximum Benefit Unlimited the entire amount must be
met before the insurance
Calendar Year Deductible* starts paying.
- Individual $2,700 $5,200
- Family $5,200 $10,400
After reaching the family de-
Co-Insurance (You Pay) 20% 50% ductible, the plan starts pay-
ing at 80% in-network, 50%
Office Visit (Co-Insurance) non-network.
- Primary Care Physician Ded, 20% Ded, 50%
- Specialist Office Visit Ded, 20% Ded, 50% For Pharmacy benefits, you
will need to reach the medi-
Out-of-Pocket Maximum cal deductible before the
- Individual $5,200 $10,400 plan will begin paying at the
- Family $7,900 $20,800 copay and coinsurance level.

Hospitalization For more info, go to
- Inpatient Ded, 20% Ded, 50% www.mycoresource.com.
- Outpatient Ded, 20% Ded, 50%
Lab and X-Ray Ded, 20% Ded, 50%
Emergency Services Ded, 20% Ded, 50%
Urgent Care Ded, 20% Ded, 50%

Preventive Care ** Pharmacy Non-Network
(This benefit includes all Preventive No Charge Ded, 50% Members will be reimbursed
Care Services required by the the contracted (discounted)
Affordable Care Act (ACA). cost of the medication minus
their applicable copay.
Chiropractic Care / Acupuncture Ded, 20% Ded, 50%

Coverage limited to 100 visits, Claims must be submitted by
$1,000 max benefit/ calendar year completing the paper claim
Skilled Nursing Facility/ Ded, 20% Ded, 50% form which can accessed
and downloaded by going
Rehabilitation Center
Coverage limited to 60 visits/ confinement to your account at
www.Caremark.com.
Home Health Care Ded. 20% Ded, 50%
Coverage limited to 100 visits/calendar year For more information, you
can also contact CVS Care-
Pharmacy Benefits Network Non Network** mark Customer Care at the
number on the back of your
Retail Rx - 30 Day Supply medical ID card.
- Generic Formulary Deductible, $10 Copay Deductible, $10 Copay
- Brand Name Formulary Deductible, the greater of Deductible, the greater of
$20 Copay or 15% $20 Copay or 15%
- Brand-Name Maximum Copay $200 $200
Mail Order Rx - 90 Day Supply
- Generic Formulary Deductible, $10 Copay Not Covered
- Brand Name Formulary Deductible, the greater of Not Covered
$20 Copay or 15%
- Brand-Name Maximum Copay $300 Not Covered

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