Page 5 - MIG Management - Benefit Guide 2018 Final 12.8.17

Benefits

Medical Insurance

Anthem Anthem
Plan Name Platinum HMO 10/10%/2000 Platinum PPO 20/10%/3000
Network Name Blue Cross HMO (CACare) - Small Blue Cross PPO (Prudent Non-Network*
Group Buyer) - Small Group
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Deductible (Annual)
- Individual None None $2,000
- Family None None $4,000

Co-Insurance (You Pay) N/A 10% 50%
Office Visit Copay
- Primary Care Physician $10 Copay $20 Copay Deductible, 50%
- Specialist Office Visit $30 Copay $40 Copay Deductible, 50%
Out-of-Pocket Maximum
- Individual $2,000 $3,000 $6,000
- Family $4,000 $6,000 $12,000

Hospitalization
- Inpatient $250 Per Day (3 Day Copay Max) 10% Deductible, 50%
- Outpatient $100 Copay 10% Deductible, 50%
Lab and X-Ray $10 Copay 10% Deductible, 50%
- Complex $100 Copay $100 Copay, 10% Deductible, 50%
Emergency Services $100 Copay $150 Copay, 10%
Urgent Care $10 Copay $40 Copay Deductible, 50%
Preventive Care No Charge No Charge Deductible, 50%

Chiropractic $10 Copay 50% Not Covered
Max 20 Visits Per Benefit Period Max 20 Visits Per Benefit Period
Pharmacy Benefits
Pharmacy Deductible
- Individual None None N/A
- Family None None N/A

Retail Pharmacy
- Tier 1a/1b $5 Copay / $15 Copay $5 Copay / $15 Copay Not Covered
- Tier 2 $35 Copay $35 Copay Not Covered
- Tier 3 $70 Copay $70 Copay Not Covered
- Supply Limit 30 Days 30 Days N/A
Mail Order Pharmacy
- Tier 1a/1b $13 Copay / $38 Copay $13 Copay / $38 Copay Not Covered
- Tier 2 $105 Copay $105 Copay Not Covered
- Tier 3 $210 Copay $210 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A

*Non-Network coverage is limited, see Anthem benefit summary for more details.

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