Page 6 - Lake Avenue Church Benefits Guide 2018 5.22

Medical Benefits

Medical Insurance

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name BASE HMO BUY-UP HMO PPO
Network Name Select HMO Select HMO In-Network Non-Network
Health Benefits S-Value Deductible HMO S-Value HMO Classic PPO 750/30/20
$500 $20/$40/20% 20/40/250/3D/20%
Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $500/person $0 $750 $2,250
- Family $500/person $0 $2,250 $6,750

Co-Insurance (Plan Pays) 100% 100% 80% 60%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay $30 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $40 Copay $30 Copay Deductible, 40%
- Live Health Online Visit $40 Copay $40 Copay $30 Copay

Chiropractic/ Acupuncture $10 Copay $10 Copay $30 Copay Deductible, 60%
(Direct referral) 30 visits/year 30 visits/year Max 30 Visits/Year Max 30 Visits/Year
Out-of-Pocket Maximum
- Individual $3,000 $3,000 $5,000 $15,000
- Family $6,000 $6,000 $10,000 $30,000

Hospitalization
- Inpatient Deductible, 20% $250/day, $750 max Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% 20% Deductible, 20% Deductible, 40%
Lab and X-Ray Deductible, 20% Deductible, 40%
- Office / Freestanding Lab 100% 100%
- Hospital Deductible, 20% 20%
Emergency Services Deductible, $150/visit, $150/visit Deductible, $150/visit, 20%
20%
Urgent Care $20/visit $20/visit $30/visit Deductible, 40%
Preventive Care 100% 100% 100% Deductible, 40%
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1a/1b Generic $5/$20 Copay $5/$20 Copay $5/$20 Copay 50% to $250
- Tier 2 Brand Name $40 Copay $40 Copay $30 Copay 50% to $250
- Tier 3 Non-Formulary $75 Copay $60 Copay $50 Copay 50% to $250
- Tier 4 Specialty 30% to $250 30% to $250 30% to $250 50% to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b Generic $12.5/$50 Copay $12.5/$50 Copay $12.5/$50 Copay Not Covered
- Tier 2 Brand Name $120 Copay $120 Copay $90 Copay Not Covered
- Tier 3 Non-Formulary $225 Copay $180 Copay $150 Copy Not Covered
- Tier 4 Specialty 30% to $250 30% to $250 30% to $250 Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
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