Page 7 - Community Health Systems Guide 2018-FINAL

Medical Benefits

Anthem Blue Cross Anthem Blue Cross
Plan Name HSA PPO
Network Network Non-Network Network Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual) Health and Pharmacy Deductible Health Deductible Only
- Individual $1,350 $4,050 $750 $2,250
- Family $3,000 $8,100 $2,250 $6,750
Co-Insurance (Plan Pays) 90% 70% 80% 60%

Office Visit Copay
- Primary Care Physician Deductible, 10% Deductible, 30% $30 Copay Deductible, 40%
- Specialist Office Visit Deductible, 10% Deductible, 30% $30 Copay Deductible, 40%
- Online Visit n/a n/a n/a n/a

Out-of-Pocket Maximum Includes Annual Deductible Includes Annual Deductible
- Individual $3,000 $9,000 $5,000 $15,000
- Family $6,000 $18,000 $10,000 $30,000

Hospitalization Deductible,
- Inpatient Deductible, 10% Deductible, 30% $500 copay without Deductible, 40%
w/limits preauthorization, then w/limits
- Outpatient Deductible, 10% Deductible, 30% 20% Deductible, 50%
w/limits w/limits
Deductible, 20%

Lab and X-Ray Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services Deductible, 10% 20% coinsurance
Urgent Care Deductible, 10% Deductible, 30% $30 Copay per visit Deductible, 40%
Preventive Care No Charge Deductible, 30% No Charge Deductible, 40%
Chiropractic/Acupuncture Deductible, 10% Deductible, 30% $30 Copay Deductible, 40%

Coverage for In-Network Providers and Non- Coverage for In-Network Providers and Non-
Network Providers combined is limited to 30 visit Network Providers combined is limited to 30
Chiro/20 visit Acu limit per benefit period. visit Chiro/20 visit Acu limit per benefit period.
Pharmacy Benefits
Pharmacy Deductible Combined with medical deductible None

Retail Pharmacy
- Tier 1A / Tier 1B Deductible, $5 / $15 Ded, + 30% up to $250 $5 / $20 Copay 50% up to $250
- Tier 2 Deductible, $40 Copay Ded, + 30% up to $250 $30 Copay 50% up to $250
- Tier 3 Deductible, $60 Copay Ded, + 30% up to $250 $50 Copay 50% up to $250
- Tier 4 30% up to $250 Ded, + 30% up to $250 30% up to $250 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy Deductible,
- Tier 1A / Tier 1B $12.50 / $37.50 Copay Not Covered $12.50 / $50 Copay Not Covered
- Tier 2 Deductible, $120 Copay Not Covered $90 Copay Not Covered
- Tier 3 Deductible, $180 Copay Not Covered $150 Copay Not Covered
- Tier 4 30% up to $250 Not Covered 30% up to $250 Not Covered
- Supply Limit 90 Days 90 Days

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