Page 8 - FINAL Crane Country Day School 2017-18 Benefits Guide

Medical Plans 8

Anthem HDHP—Solutions PPO $3,500
In-Network Out-of-Network

You Pay You Pay
Plan Basics
Calendar Year Deductible Individual: $3,500 Individual: $10,500
Family: $7,000 Family: $21,000

Calendar Year Out-of-Pocket Maximum Individual: $6,350 Individual: $19,050
Family: $12,700 Family: $38,100

Lifetime Maximum Benefit Unlimited Unlimited

Medical Benefits
Doctor’s Office Visits $30 copay Deductible, 50%

Preventive Care/Well Baby Care $0 copay Deductible, 50%

Chiropractic $30 copay Deductible, 50%

X-Ray & Lab Deductible, 70% Deductible, 50%

MRI, CT and PET Scans Deductible, 70% Deductible, 50%

Urgent Care $30 copay Deductible, 50%
Hospital Benefits
Hospitalization Deductible, 70% Deductible, 50%

Outpatient Surgery Deductible, 70% Deductible, 50%

Emergency Room $150 copay then 70% $150 copay then 70%

Prescription Drug Benefits
Retail (30-Day Supply)
Tier 1a—Low Cost Generic $5 copay $5 + 50% of retail
Tier 1b—Generic $20 copay $20 + 50% of retail
Tier 2—Formulary Brand $40 copay $40 + 50% of retail
Tier 3—Non-Formulary Brand $60 copay $60 + 50% of retail

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