Page 8 - Premier EE Guide 12-17 - CA Final

BENEFITS

MEDICAL INSURANCE

Anthem Blue Cross
Plan Name Lumenos HSA

Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited
Deductible (Calendar Year)
- Individual $2,600 $7,800
- Family $5,200 $15,600
Co-Insurance (Plan Pays) 100% 70%
Office Visit Copay
- Primary Care Physician Deductible, 0% Deductible, 30%
- Specialist Office Visit Deductible, 0% Deductible, 30%
Out-of-Pocket Maximum
- Individual $5,000 $15,000
- Family $10,000 $30,000

Hospitalization
- Inpatient Deductible, 0% Deductible, 30%*
- Outpatient Deductible, 0% Deductible, 30%*
Lab and X-Ray
- Diagnostic Deductible, 0% Deductible, 30%*
- Complex Deductible, 0% Deductible, 30%*
Emergency Services Deductible, 0%

Urgent Care Deductible, 0% Deductible, 30%
Preventive Care No Charge Deductible, 30%
Chiropractic Deductible, 0% Deductible, 30%
30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible Health Deductible Applies Health Deductible Applies
Retail Pharmacy
- Tier 1a/1b (typically generic) $5/$15 Copay 30% up to $250 max/Rx
- Tier 2 (typically preferred/brand) $40 Copay 30% up to $250 max/Rx
- Tier 3 (typically non-preferred) $60 Copay 30% up to $250 max/Rx
- Tier 4 (typically specialty drugs) 30% up to $250 max/Rx 30% up to $250 max/Rx
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b (typically generic) $12.50/$37.50 Copay Not Covered
- Tier 2 (typically preferred/brand) $120 Copay Not Covered
- Tier 3 (typically non-preferred) $180 Copay Not Covered
- Tier 4 (typically specialty drugs) 30% up to $250 max/Rx Not Covered
- Supply Limit 90 Days (Tier 4 is 30 days)

*Limitations apply. See SBC for details.

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