Page 6 - Avance Schools Benefit Guide 2019

BENEFITS

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name BASE HMO Buy-up HMO PPO
“Be Active”
Network Name Priority Select HMO Select HMO Prudent Buyer PPO Non-Network
HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual None None $500 $1,500
- Family None None $1,500 $4,500

Co-Insurance (Plan Pays) 100% 100% 80% 60%
Office Visit Copay
- Preventive Care No Charge No Charge No Charge Deductible, 40%
- Primary Care Physician $20 Copay $10 Copay $20 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $30 Copay $20 Copay Deductible, 40%
- Urgent Care $20 Copay $10 Copay $20 Copay Deductible, 40%
- Telemedicine $49 Copay $49 Copay $20 Copay N/A

Out-of-Pocket Maximum
- Individual $2,000 $2,000 $3,500 $10,500
- Family $4,000 $4,000 $7,000 $21,000
Hospitalization
- Inpatient $250 Copay $250 Copay Deductible, 20% Deductible, 40%*
- Outpatient Surgery $125 Copay $125 Copay Deductible, 20% Deductible, 40%*
Lab and X-Ray
- Diagnostic No Charge No Charge Deductible, 20% Deductible, 40%*
- Advanced Imaging $100 Copay per Test $100 Copay per Test Deductible, 20% Deductible, 40%*

Emergency Services $100 Copay $100 Copay Deductible, $150 Copay, 20%
Chiropractic $10 Copay $10 Copay $20 Copay Deductible, 40%
30 Visits/Year 30 Visits/Year 30 Visits/Year
PHARMACY BENEFITS

Pharmacy Deductible None None None None
Retail Pharmacy
- Tier 1a / 1b $5 / $15 Copay $5 / $15 Copay $5 / $15 Copay 50% Max $250 Copay
- Tier 2 $30 Copay $30 Copay $30 Copay 50% Max $250 Copay
- Tier 3 $50 Copay $50 Copay $50 Copay 50% Max $250 Copay
- Tier 4 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay 50% Max $250 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
50
50
50
50
50
- Tier 1a / 1b $12 / $37 Copay $12 / $37 Copay $12 / $37 Copay Not Covered
- Tier 2 $90 Copay $90 Copay $90 Copay Not Covered
- Tier 3 $150 Copay $150 Copay $150 Copay Not Covered
- Tier 4 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
*Limits apply. See SBC for details.
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