Page 7 - Inglewood USD Benefits Guide 2019 - Retiree_FINAL

BENEFITS

Retiree Cost $$$ $$$
Option 6 Option 7

Anthem Anthem
Plan Name Classic 500 PPO Solutions 2000 PPO

Network Name Prudent Buyer Non-Network Prudent Buyer Non-Network
Network Size AAAA N/A AAAA N/A
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $500 $1,500 $2,000 $6,000
- Family $1,500 $4,500 $6,000 $12,000
Out-of-Pocket Maximum
- Individual $3,250 $12,000 $6,350 $12,000
- Family $9,750 $24,000 $12,700 $24,000

Co-Insurance (Plan Pays) 80% 60% 80% 60%
Office Visit Copay
- Preventive Care No Charge Deductible, 40% No Charge Deductible, 40%
- Primary Care Physician $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Specialist Office Visit $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Urgent Care $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
Hospitalization
1
- Inpatient Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%

Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
- Complex Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%

Emergency Services Deductible, $100 Copay, 20% Deductible, $100 Copay, 20%
Chiropractic Deductible, 20% Deductible, 40% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1 (Generic) $7 Copay 50% up to $250 $7 Copay 50% up to $250
- Tier 2 (Brand-Name) $25 Copay 50% up to $250 $25 Copay 50% up to $250
- Tier 3 (Non-Formulary) $40 Copay 50% up to $250 $40 Copay 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 (Generic) $15 Copay Not Covered $15 Copay Not Covered
- Tier 2 (Brand-Name) $60 Copay Not Covered $60 Copay Not Covered
- Tier 3 (Non-Formulary) $90 Copay Not Covered $90 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
1
Facility Fee ($500 copay) applies if you do not receive preauthorization. See your Summary of Benefits for details.
2 Out-of-Network Services may have a benefit or payment limit. See your Summary of Benefits for details.
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