Page 7 - FINAL Crane Country Day School 2017-18 Benefits Guide

Medical Plans 7

Anthem HSA– Lumenos $2,000/$4,000
In-Network Out-of-Network

You Pay You Pay
Plan Basics
Calendar Year Deductible Individual: $2,000 Individual: $6,000
Member of Family: $2,600 Member of Family: $6,000
Family: $4,000 Family: $12,000

Calendar Year Out-of-Pocket Maximum Individual: $3,000 Individual: $9,000
Member of Family: $3,000 Member of Family: $9,000
Family: $6,000 Family: $18,000

Lifetime Maximum Benefit Unlimited Unlimited

Medical Benefits
Doctor’s Office Visits Deductible, 80% Deductible, 60%

Preventive Care/Well Baby Care $0 copay Deductible, 60%

Chiropractic
Deductible, 80% Deductible, 60%
X-Ray & Lab
Deductible, 80% Deductible, 60%
MRI, CT and PET Scans
Deductible, 80% Deductible, 60%
Urgent Care
Deductible, 80% Deductible, 60%
Hospital Benefits
Hospitalization Deductible, 80% Deductible, 60%

Outpatient Surgery Deductible, 80% Deductible, 60%

Emergency Room Deductible, 80% Deductible, 80%
Prescription Drug Benefits Subject to Medical Deductible Subject to Medical Deductible
Retail (30-Day Supply)
Tier 1a—Low Cost Generic $5 copay 40% of retail up to $250
Tier 1b—Generic $15 copay 40% of retail up to $250
Tier 2—Formulary Brand $40 copay 40% of retail up to $250
Tier 3—Non-Formulary Brand $60 copay 40% of retail up to $250

Mail Order (90-Day Supply)
Tier 1a—Low Cost Generic $12.50 copay Not covered
Tier 1b—Generic $50 copay Not covered
Tier 2—Formulary Brand $120 copay Not covered
Tier 3—Non-Formulary Brand $180 copay Not covered

* Footnote: This is only a summary of benefits. Please refer to plan documents for full details.

To Find an Anthem Provider: www.anthem.com/ca