Page 5 - NickCo Hospitality_2017 EE Benefits Guide_Mgmt_12.08.16

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Value HMO Solutions PPO
Network Name Select HMO Prudent Buyer PPO Non‐Network
Health Benefits
Life me Maximum Benefit Unlimited Unlimited

Deduc ble (Annual)
‐ Individual $0 $1,500 $4,500
‐ Family $0 $3,000 $9,000
Co‐Insurance (Plan Pays) 100% 80% 60%
Office Visit Copay
‐ Primary Care Physician $30 Copay $15 Copay Deduc ble, 40%
‐ Specialist Office Visit $40 Copay $15 Copay Deduc ble, 40%
‐ LiveHealth Online $49 Copay $10 Copay N/A
Out‐of‐Pocket Maximum
‐ Individual $5,000 $3,500 $10,500
‐ Family $10,000 $7,000 $21,000

Hospitaliza on
‐ Inpa ent 30% Deduc ble, 20% Deduc ble, 40%
‐ Outpa ent 30% Deduc ble, 20% Deduc ble, 40%
Emergency Services $200 Copay $150 Copay, 20%
Ambulance Services (Emergency) $100 Copay Deduc ble, 20%
Urgent Care $30 Copay $15 Copay Deduc ble, 40%

Preven ve Care No Charge No Charge Deduc ble, 40%
Chiroprac c $30 Copay $15 Copay Deduc ble, 40%
60 Day Limit Max 30 Visits/Year
Pharmacy Benefits

Pharmacy Deduc ble
‐ Individual $150 $0 $0
‐ Family $450 $0 $0
Retail Pharmacy
‐ Tier 1a / 1b $5 / $20 Copay $5 / $20 Copay 50%
‐ Tier 2 Deduc ble, $40 Copay $40 Copay 50%
‐ Tier 3 Deduc ble, $60 Copay $60 Copay 50%
‐ Tier 4 30% Max $250 Copay 30% Max $250 Copay 50%
‐ Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
‐ Tier 1a / 1b $12.50 / $50 Copay $12.50 / $50 Copay Not Covered
‐ Tier 2 Deduc ble, $120 Copay $120 Copay Not Covered
‐ Tier 3 Deduc ble, $180 Copay $180 Copay Not Covered
‐ Tier 4 30% Max $250 Copay 30% Max $250 Copay Not Covered
‐ Supply Limit 90 Days 90 Days N/A

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