Page 7 - OrangeTheory Benefits Guide 2018-2019 Final

Medical Benefits– PPO

Anthem Blue Cross
Plan Name
PPO
Platinum PPO
Network Name Out-of-Network
200/10/3000 (3037)
Health Benefits
Lifetime Maximum Unlimited

Deductible (Annual)
- Individual $200 $400
- Family $600 (embedded) $800 (embedded)
Co-Insurance (Plan Pays) 90% 50%

Office Visit Copay
- Primary Care Physician $10 (ded. waived) 50% after ded.
- Specialist Office Visit $30 (ded. waived) 50% after ded.

Out-of-Pocket Maximum
- Individual $3,000 (includes ded.) $6,000 (includes ded.)
- Family $6,000 (embedded; includes ded.) $12,000 (embedded; includes ded.)
Hospitalization
- Inpatient 10% after ded. 50% after ded. ($650 max/day)
- Outpatient 10% after ded. 50% after ded. ($380 max/day)

Lab and X-Ray 10% after ded. 50% after ded.
Imaging (CT/PET Scans, MRIs) 10% after ded. then $100/visit 50% after ded. ($380 max/procedure)
Emergency Room $200 + 10% after ded.

Emergency Transport/Ambulance 10% after ded.
Urgent Care $20 (ded. waived) 50% after ded.
Preventive Care $0 50% after ded.

50% (ded. waived) Not Covered
Chiropractic
20 visits per benefit period
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 Not Covered
- Family $0 Not Covered
Retail Pharmacy
- Generic Formulary (Tier 1) $5/$15 Not Covered
- Preferred Brand Formulary (Tier 2) $35 Not Covered
- Non-Preferred Formulary (Tier 3) $70 Not Covered
- Specialty (Tier 4) 30% up to $250 Not Covered

Mail Order Pharmacy
- Generic Formulary (Tier 1) 2.5x Retail Not Covered
- Preferred Brand Formulary (Tier 2) 3x Retail Not Covered
- Non-Preferred Formulary (Tier 3) 3x Retail Not Covered

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