Page 8 - Column Five EE Guide 12-19 -National

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Gold PPO 30/750/20% Gold PPO 30/500/20%
Network Name Prudent Buyer Non-Network Prudent Buyer Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $750 $2,000 $500 $2,000
- Family $2,250 $4,000 $1,500 $4,000
Out-of-Pocket Maximum
- Individual $7,000 $14,000 $6,800 $13,600
- Family $14,000 $28,000 $13,600 $27,200

Co-Insurance (Plan Pays) 80% 50% 80% 50%
Office Visit Copay
- Preventive Care No Charge Deductible, 50% No Charge Deductible, 50%
- Primary Care Physician $30 Copay Deductible, 50% $30 Copay Deductible, 50%
- Specialist Office Visit $55 Copay Deductible, 50% $60 Copay Deductible, 50%
- Urgent Care $55 Copay Deductible, 50% $60 Copay Deductible, 50%
- Live Health Online $15 Copay Not covered $15 Copay Not covered

Hospitalization
- Inpatient Deductible, 20% Deductible, 50%* Deductible, 20% Deductible, 50%*
- Outpatient Surgery Deductible, 20% Deductible, 50%* Deductible, 20% Deductible, 50%*
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 50%
- Complex Deductible, 20%, $100 Deductible, 50%* Deductible, 20%, $100 Deductible, 50%*
Emergency Services Deductible, $250 Copay, 20% Deductible, $250 Copay, 20%

Chiropractic Deductible, 50% Not covered Deductible, 50% Not covered
20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $250 N/A $250 N/A
- Family $500 N/A $500 N/A

Retail (30 Day Supply) Waived for generics Waived for generics
- Generic Formulary $20 Copay Not Covered $20 Copay Not Covered
- Brand Name Formulary $40 Copay Not Covered $40 Copay Not Covered
- Non-Formulary $80 Copay Not Covered $80 Copay Not Covered
- Specialty 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered
Mail Order (90 Day Supply)
- Generic Formulary $13/$50 Copay Not Covered $13/$50 Copay Not Covered
- Brand Name Formulary $120 Copay Not Covered $120 Copay Not Covered
- Non-Formulary $240 Copay Not Covered $240 Copay Not Covered
- Specialty 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered

*Limitations apply. See SBC for details.

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