Page 5 - NickCo Hospitality_2017 EE Benefits Guide_Hourly Associates_12.08.16

BENEFITS

Medical Insurance

Anthem Blue Cross
Plan Name Elements HMO

Network Name Select HMO
Health Benefits
Life me Maximum Benefit Unlimited
Deduc ble (Annual)
‐ Individual $1,500
‐ Family $1,500 per Member
Co‐Insurance (Plan Pays) 100%
Office Visit Copay
‐ Primary Care Physician $25 Copay
‐ Specialist Office Visit $50 Copay
‐ LiveHealth Online $49 Copay
Out‐of‐Pocket Maximum
‐ Individual $6,400
‐ Family $12,800
Hospitaliza on
‐ Inpa ent Deduc ble, 30%
‐ Outpa ent Deduc ble, 30%

Emergency Services $250 Copay, 30%
Ambulance Services (Emergency) $100 Copay
Urgent Care $25 Copay
Preven ve Care No Charge

Chiroprac c $25 Copay
60 Day Limit
Pharmacy Benefits

Pharmacy Deduc ble
‐ Individual $500
‐ Family $1,500

Retail Pharmacy
‐ Tier 1a / 1b $5 / $20 Copay
‐ Tier 2 Deduc ble, $50 Copay
‐ Tier 3 Deduc ble, $65 Copay
‐ Tier 4 30% Max $250 Copay
‐ Supply Limit 30 Days

Mail Order Pharmacy
‐ Tier 1a / 1b $12.50 / $50 Copay
‐ Tier 2 Deduc ble, $150 Copay
‐ Tier 3 Deduc ble, $195 Copay
‐ Tier 4 30% Max $250 Copay
‐ Supply Limit 90 Days

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