Page 7 - Premier EE Guide 12-17 - Texas final

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross
Plan Name PPO Lumenos HSA
Network Network Non-Network Network Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Calendar Year)
- Individual $500 $1,500 $2,600 $7,800
- Family $1,500 $4,500 $5,200 $15,600

Co-Insurance (Plan Pays) 80% 60% 100% 70%
Office Visit Copay
- Primary Care Physician $30 Copay Deductible, 40% Deductible, 0% Deductible, 30%
- Specialist Office Visit $30 Copay Deductible, 40% Deductible, 0% Deductible, 30%

Out-of-Pocket Maximum
- Individual $4,000 $12,000 $5,000 $15,000
- Family $8,000 $24,000 $10,000 $30,000

Hospitalization
- Inpatient Deductible, 20% Deductible, 40%* Deductible, 0% Deductible, 30%*
- Outpatient Deductible, 20% Deductible, 40%* Deductible, 0% Deductible, 30%*
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40%* Deductible, 0% Deductible, 30%*
- Complex Deductible, 20% Deductible, 40%* Deductible, 0% Deductible, 30%*

Emergency Services $150 Copay, 20% $150 Copay, 20% Deductible, 0%
Urgent Care $30 Copay Deductible, 40% Deductible, 0% Deductible, 30%
Preventive Care No Charge Deductible, 40% No Charge Deductible, 30%

Chiropractic $30 Copay Deductible, 40% Deductible, 0% Deductible, 30%
30 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible $0 $0 Health Deductible Applies
Retail Pharmacy
- Tier 1a/1b (typically generic) $5/$15 Copay Copay + 50% $5/$15 Copay 30% up to $250/Rx
- Tier 2 (typically preferred/brand) $30 Copay Copay + 50% $40 Copay 30% up to $250/Rx
- Tier 3 (typically non-preferred) $50 Copay Copay + 50% $60 Copay 30% up to $250/Rx
- Tier 4 (typically specialty drugs) 30% up to $250/Rx Copay + 50% 30% up to $250/Rx 30% up to $250/Rx
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1a/1b (typically generic) $12.50/$37.50 Copay Not Covered $12.50/$37.50 Copay Not Covered
- Tier 2 (typically preferred/brand) $90 Copay Not Covered $120 Copay Not Covered
- Tier 3 (typically non-preferred) $150 Copay Not Covered $180 Copay Not Covered
- Tier 4 (typically specialty drugs) 30% up to $250/Rx Not Covered 30% up to $250/Rx Not Covered
- Supply Limit 90 Days N/A 90 Days (Tier 4 is 30 N/A
*Limitations apply. See SBC for details. days)

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