Page 6 - Oremor EE Guide 01-18_FINAL1
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Benefits





         Medical Insurance



                                        EBA&M (Anthem Blue Cross)               EBA&M (Anthem Blue Cross)
         Plan Name                             Network PPO                                  PPO
         Network Name                             Network                     Network               Non-Network
         Health Benefits
         Lifetime Maximum Benefit                 Unlimited                               Unlimited

         Deductible (Annual)
          - Individual                              $100                                    $250
          - Family Limit                            $200                                    $500
         Co-Insurance (Plan Pays)                   80%                         90%                    60%
         Office Visit Copay
          - LiveHealth Online                    $10 Copay                    $10 Copay                 N/A
          - Primary Care Physician               $20 Copay                    $15 Copay            Deductible, 60%
          - Specialist Office Visit              $50 Copay                    $15 Copay            Deductible, 60%
         Out-of-Pocket Maximum
          - Individual                             $4,000                      $3,000                 $10,000
          - Family Limit                           $8,000                      $6,000                 $20,000

         Hospitalization
          - Inpatient                          Deductible, 20%             Deductible, 10%         Deductible, 40%
                                                                                                Max $600 Benefit/Day
          - Outpatient                         Deductible, 20%             Deductible, 10%         Deductible, 40%
                                                                                                Max $600 Benefit/Day
         Emergency Services                    $150 Copay, 20%                         $100 Copay, 10%
         Urgent Care                             $20 Copay                 Deductible, 10%         Deductible, 40%

         Preventive Care                         No Charge                    No Charge             Not Covered
         Physical Therapy / Physical             $50 Copay                    $15 Copay            Deductible, 40%
         Medicine & Occupational                                                                Max $25 Benefit/Visit
         Therapy / Speech Therapy
                                              Max 24 Visits/Year                      Max 24 Visits/Year
         Pharmacy Benefits
         Specialty Out-of-Pocket Maximum
          - Individual                             $7,350                       N/A                     N/A
          - Family                                $14,700                       N/A                     N/A

         Retail Pharmacy
          - Generic Formulary                    $10 Copay                    $10 Copay             Not Covered
          - Brand Name Formulary                 $30 Copay                    $25 Copay             Not Covered
          - Non-Formulary                      50% to $150 Max                $50 Copay             Not Covered
          - Specialty                          30% to $500 Max                  N/A                 Not Covered
          - Supply Limit                          30 Days                      30 Days                  N/A
         Mail Order Pharmacy
          - Generic Formulary                    $20 Copay                    $20 Copay             Not Covered
          - Brand Name Formulary                 $60 Copay                    $50 Copay             Not Covered
          - Non-Formulary                       50% Max $300                 $100 Copay             Not Covered
          - Specialty                    30% Max $500 (30 Day Supply)           N/A                 Not Covered
          - Supply Limit                          90 Days                      90 Days                  N/A

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