Page 6 - SBCEO Benefit Guide 19-20_FINAL

Medical Benefits 6

Anthem 100-C $20 Classic Anthem 100/80 SB PBI
PPO #40461D PPO #40482A
Plan Basics In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible Individual: $200 Individual: $100
Family: $400 Family: $300
Annual Out-of-Pocket Individual: $1,000 No limit Individual: $1,000 No limit
Maximum Family: $3,000 Family: $3,000
Medical Services You Pay You Pay You Pay You Pay
2
1
Office Visit $20 copay Non-Par Fee No charge 20%
(deductible waived)
Telemedicine (MDLive) $5 copay Not covered $5 copay Not covered
2
1
Urgent Care $20 copay Non-Par Fee No charge 20%
Preventive Care No charge Not covered No charge 20% 2
(deductible waived) (deductible waived) (deductible waived)
2
1
Hospitalization No charge Non-Par Fee No charge 20%
(covered up to $600/
day)
2
Diagnostic Lab and No charge Not covered No charge 20%
X-Ray
2
1
Complex Imaging No charge Non-Par Fee No charge 20%
(covered up to $800/
test)
1
Emergency Room $100 copay $100 copay, $50 copay $50 copay
1
(copay waived if admitted) Non-Par Fee
3
Physical Medicine You Pay You Pay You Pay You Pay
2
Physical Therapy, No charge Not covered No charge 20%
Occupational Therapy,
Chiropractic
4
Navitus Rx Benefits You Pay You Pay You Pay You Pay
Retail Pharmacy
− Generic Formulary $0 - $9 copay Not Covered $0 - $5 copay Not Covered
− Brand Name Formulary $35 copay $10 copay

Mail Order Pharmacy
− Generic Formulary $0 copay Not Covered $0 copay Not Covered
− Brand Name Formulary $90 copay $0 - $20 copay

1 Anthem pays scheduled amount; you are responsible for any difference between covered expense and actual changes, in addition to any
applicable deductible or copay.
2 Anthem pays 80% of customary and reasonable charges (as determined by Anthem); you are responsible for any difference between covered
expenses and actual changes, in addition to any applicable deductible or copay.
3 Must be medically necessary; no allowance for maintenance; subject to review after 5 visits.
4 If you use a Brand Name drug when a Generic drug is available, you are responsible for paying the difference in cost between the Generic and
the Brand Name drug.

Navitus Rx Contact Information

Call 866-333-2757 or visit navitus.com.