Page 7 - 360 Behavioral Health Guide 2018-2019 Final

Medical Benefits

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name
Classic PPO Solutions PPO PPO HSA

PPO Prudent Non-Network PPO Prudent Non-Network PPO Prudent Non-Network
Network Name Buyer Buyer Buyer
Network Network Network
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $500 $1,500 $2,500 $5,000 $2,700 $8,100
- Family $1,000 $3,000 $5,000 $10,000 $5,400 $16,200

Co-Insurance (Plan Pays) 80% 60% 80% 60% 80% 50%
Office Visit Copay
- Primary Care Physician $30 Copay Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%
- Specialist Office Visit $40 Copay Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%

Out-of-Pocket Maximum
- Individual $2,500 $5,500 $6,350 $12,500 $5,000 $15,000
- Family $5,000 $11,000 $12,700 $25,000 $10,000 $30,000

Hospitalization
- Inpatient Ded, 80% Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%
- Outpatient Ded, 80% Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%

Lab and X-Ray Ded, 80% Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%
Emergency Services Ded, $150 Copay, 80% Ded, 80% Ded, 80%

Urgent Care $50 Copay Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%
Preventive Care 100% Ded, 60% 100% Ded, 60% 100% Ded, 50%

Chiropractic $30 Copay Ded, 60% Ded, 80% Ded, 60% Ded, 80% Ded, 50%
30 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible Medical deductible must be
- Individual $0 $0 $0 $0 met before prescriptions
- Family $0 $0 $0 $0 copays apply

Retail Pharmacy
- Generic Formulary $15 Copay 50% up to $250 $15 Copay 50% up to $250 $15 Copay 50% up to $250
- Brand Name Formulary $30 Copay 50% up to $250 $30 Copay 50% up to $250 $40 Copay 50% up to $250
- Non-Formulary $50 Copay 50% up to $250 $50 Copay 50% up to $250 $60 Copay 50% up to $250
- Specialty $50 Copay 50% up to $250 $50 Copay 50% up to $250 30% up to 50% up to $250
$250

Mail Order Pharmacy
- Generic Formulary $30 Copay Not Covered $30 Copay Not Covered $37.50 Copay Not Covered
- Brand Name Formulary $60 Copay Not Covered $60 Copay Not Covered $120 Copay Not Covered
- Non-Formulary $100 Copay Not Covered $100 Copay Not Covered $180 Copay Not Covered

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