Page 6 - OrangeTheory Benefits Guide 2018-2019 Final

Medical Benefits– HMO

Anthem Blue Cross Anthem Blue Cross
Plan Name
HMO HMO
Silver Select HMO Gold Select HMO
Network Name
2000/40/7350 (2XYY) 500/20/5000 (2XYQ)
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $2,000 $500
- Family $4,000 (embedded) $1,500 (embedded)

Co-Insurance (Plan Pays) 60% 80%
Office Visit Copay
- Primary Care Physician $55 (ded. waived) $30 (ded. waived)
- Specialist Office Visit $100 (ded. waived) $60 (ded. waived)
Out-of-Pocket Maximum
- Individual $7,350 (includes ded.) $5,000 (includes ded.)
- Family $14,700 (embedded; includes ded.) $10,000 (embedded; includes ded.)

Hospitalization
- Inpatient 40% after ded. 20% after ded.
- Outpatient 40% after ded. 20% after ded.
Lab and X-Ray $25 (ded. waived) $25 (ded. waived)
Imaging (CT/PET Scans, MRIs)
- Inpatient $100 (ded. waived) 20% after ded.
- Outpatient $300 after ded.
Emergency Room $325 + 40% after ded. $250 + 20% after ded.

Emergency Transport/Ambulance 40% after ded. 20% after ded.
Urgent Care $55 (ded. waived) $50 (ded. waived)
Preventive Care $0 $0

$55 (ded. waived) $30 (ded. waived)
Chiropractic
20 visits per benefit period 20 visits per benefit period
Pharmacy Benefits
Pharmacy Deductible (Subject to Tiers 2-4; Select Rx)
- Individual $0 $250
- Family $0 $500
Retail Pharmacy
- Generic Formulary (Tier 1) $5/$20 $5/$20
- Preferred Brand Formulary (Tier 2) $70 $40
- Non-Preferred Formulary (Tier 3) $110 $80
- Specialty (Tier 4) 30% up to $250 30% up to $250
Mail Order Pharmacy
- Generic Formulary (Tier 1) 2.5x Retail 2.5x Retail

- Preferred Brand Formulary (Tier 2) 3x Retail 3x Retail
- Non-Preferred Formulary (Tier 3) 3x Retail 3x Retail

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