Page 7 - Career Group Benefits Guide 2020 OOS

Medical Plan Highlights

Anthem Blue Cross Anthem Blue Cross
Plan Name EPO PPO

Blue Cross PPO
(Prudent Buyer) Large Blue Cross PPO (Prudent
Network Name Group Buyer) Large Group Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $1,000 $750 $2,250
- Family $3,000 $2,250 $6,750
Out-of-Pocket Maximum
- Individual $5,500 $5,000 $15,000
- Family $11,000 $10,000 $30,000

Co-Insurance (Plan Pays) 80% 80% 60%

Office Visit Copay
- Preventive Care No Charge No Charge Deductible, 40%
- Primary Care Physician $20 Copay $30 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $50 Copay Deductible, 40%
- Urgent Care $20 Copay $30 Copay Deductible, 40%
- Telemedicine $10 Copay $10 Copay Deductible, 40%

Hospitalization
- Inpatient Deductible, 20% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 20% Deductible, 40%
- Complex Deductible, 20% Deductible, 20% Deductible, 40%
Emergency Services Deductible,$150 Deductible,$150 Copay, 20%
Copay, 20%
Chiropractic $20 Copay $30 Copay Deductible, 40%
30 Visits/Year 30 Visits/Year

Pharmacy Benefits
Pharmacy Deductible None None None
Retail Pharmacy
- Generic Formulary $5/$20 Copay $5/$20 Copay 50% to $250
- Brand Name Formulary $40 Copay $30 Copay 50% to $250
- Non-Formulary $60 Copay $50 Copay 50% to $250
- Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $12.50/$50 Copay $12.50/$50 Copay Not Covered
- Brand Name Formulary $120 Copay $90 Copay Not Covered
- Non-Formulary $180 Copay $150 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A

Employee Benefits 7