Page 7 - Community Health Systems Guide 2020 v2 (CHSI Review)

Medical Benefits

Anthem Blue Cross Anthem Blue Cross
Plan Name PPO HSA-H 1400/2800/3000 10/30 Classic PPO 750/30/50/2
Network Prudent Buyer PPO Non-Network Prudent Buyer PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual) Health and Pharmacy Deductible Health Deductible Only
- Individual $1,400 $4,200 $750 $2,250
- Family $3,000 $8,400 $2,250 $6,750
Co-Insurance (Plan Pays) 90% 70% 80% 60%
Office Visit Copay
- Primary Care Physician Deductible, 10% Deductible, 30% $30 Copay Deductible, 40%
- Specialist Office Visit Deductible, 10% Deductible, 30% $50 Copay Deductible, 40%
- Online Visit $59 Copay; n/a $10 Copay n/a
$10 after Deductible

Out-of-Pocket Maximum Includes Annual Deductible Includes Annual Deductible
- Individual $3,000 $9,000 $5,000 $15,000
- Family $6,000 $18,000 $10,000 $30,000

Hospitalization Deductible,
- Inpatient Deductible, 10% Deductible, 30% $500 copay without Deductible, 40%
w/limits preauthorization, then w/limits
20%
- Outpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
w/limits w/limits

Lab and X-Ray Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services Deductible, 10% $150 + Deductible, 20%
Urgent Care Deductible, 10% Deductible, 30% $30 Copay per visit Deductible, 40%

Preventive Care No Charge Deductible, 30% No Charge Deductible, 40%
Chiropractic/Acupuncture Deductible, 10% Deductible, 30% $30 Copay Deductible, 40%
Coverage for In-Network Providers and Non- Coverage for In-Network Providers and Non-
Network Providers combined is limited to 30 visit Network Providers combined is limited to 30
Chiro/20 visit Acu limit per benefit period. visit Chiro/20 visit Acu limit per benefit period.
Pharmacy Benefits

Pharmacy Deductible Combined with medical deductible None
Retail Pharmacy
- Tier 1A / Tier 1B Deductible, $5 / $15 Ded, + 30% up to $250 $5 / $20 Copay 50% up to $250
- Tier 2 Deductible, $40 Copay Ded, + 30% up to $250 $30 Copay 50% up to $250
- Tier 3 Deductible, $60 Copay Ded, + 30% up to $250 $50 Copay 50% up to $250
- Tier 4 30% up to $250 Ded, + 30% up to $250 30% up to $250 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy Deductible,
- Tier 1A / Tier 1B $12.50 / $37.50 Copay Not Covered $12.50 / $50 Copay Not Covered
- Tier 2 Deductible, $120 Copay Not Covered $90 Copay Not Covered
- Tier 3 Deductible, $180 Copay Not Covered $150 Copay Not Covered
- Tier 4 30% up to $250 Not Covered 30% up to $250 Not Covered
- Supply Limit 90 Days 90 Days
7