Page 6 - TCR Benefit Guide 2017 - Non-CA - sent 9.12.17

Benefits

Medical Insurance

Anthem
Plan Name PPO
Network Name PPO Network Non-Network
Health Benefits

Lifetime Maximum Benefit Unlimited
Deductible (Annual)
- Individual $750 $2,250
- Family $2,250 $6,750
Co-Insurance (You Pay) 20% 40%
Office Visit Copay
- Primary Care Physician $30 Copay Ded, 40%
- Specialist Office Visit $30 Copay Ded, 40%
Out-of-Pocket Maximum
- Individual $5,000 $15,000
- Family $10,000 $30,000
Hospitalization
- Inpatient Ded, 20% Ded, 40% ($1,000 Benefit Max)
Ded, 40% ($350 Benefit Max)
- Outpatient Ded, 20%

Lab and X-Ray Ded, 20% Ded, 40% ($800 Benefit Max)

Emergency Services Ded, $150, 20%
Urgent Care $30 Copay Ded, 40%
Preventive Care No Charge Ded, 40%
Mental Health
- Inpatient Ded, 20% Ded, 40% ($1,000 Benefit Max)
Ded, 40%
- Outpatient $30 Copay
Pharmacy Benefits

Pharmacy Deductible
- Individual none none
- Family none none

Retail Pharmacy
- Tier 1a/1b $5/$20 Copay 50%
- Tier 2 $30 Copay 50%
- Tier 3 $50 Copay 50%
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $12.50/$50 Copay Not Covered
- Tier 2 $90 Copay Not Covered
- Tier 3 $150 Copay Not Covered
- Supply Limit 90 Days N/A

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