Page 5 - NickCo Mgmt Benefits Flipbook

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Value HMO Solutions PPO
Network Name Select HMO Prudent Buyer PPO Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Deductible (Annual)
- Individual $0 $1,500 $4,500
- Family $0 $3,000 $9,000
Co-Insurance (Plan Pays) 100% 80% 60%
Office Visit Copay
- Primary Care Physician $30 Copay $15 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $15 Copay Deductible, 40%
- LiveHealth Online $49 Copay $10 Copay N/A
Out-of-Pocket Maximum
- Individual $5,000 $3,500 $10,500
- Family $10,000 $7,000 $21,000

Hospitalization
- Inpatient 30% Deductible, 20% Deductible, 40%
- Outpatient 30% Deductible, 20% Deductible, 40%
Emergency Services $200 Copay $150 Copay, 20%
Ambulance Services (Emergency) $100 Copay Deductible, 20%
Urgent Care $30 Copay $15 Copay Deductible, 40%

Preventive Care No Charge No Charge Deductible, 40%
Chiropractic $30 Copay $15 Copay Deductible, 40%
60 Day Limit Max 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $150 $0 $0
- Family $450 $0 $0
Retail Pharmacy
- Tier 1a / 1b $5 / $20 Copay $5 / $20 Copay 50%
- Tier 2 Deductible, $40 Copay $40 Copay 50%
- Tier 3 Deductible, $60 Copay $60 Copay 50%
- Tier 4 30% Max $250 Copay 30% Max $250 Copay 50%
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a / 1b $12.50 / $50 Copay $12.50 / $50 Copay Not Covered
- Tier 2 Deductible, $120 Copay $120 Copay Not Covered
- Tier 3 Deductible, $180 Copay $180 Copay Not Covered
- Tier 4 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A

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