Page 6 - CHSI Benefit Guide 2019-2020
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Medical Benefits
Anthem Blue Cross
Plan Name HMO
Network Full Network (Blue Cross HMO (CACare) - Large Group)
Health Benefits
Lifetime Maximum Unlimited
Deductible (Annual) None
Office Visit Copay
- Primary Care Physician $20 Copay
- Specialist Office Visit $40 Copay
- Online Visit $49 Copay
Out-of-Pocket Maximum
- Individual $2,000
- Family $4,000
Hospitalization
- Inpatient $250 per admission
- Outpatient $125 copay per admission
Lab and X-Ray No charge
Emergency Services $100 Copay per visit
Urgent Care $20 Copay
Preventive Care No Charge
Chiropractic / Acupuncture $20 Copay
Coverage for In-Network Provider is limited to 60 days limit per ben-
efit period for Physical, Occupational and Speech Therapy combined.
Chiropractic visits count towards your physical and occupational
therapy limit.
Pharmacy Benefits
Pharmacy Deductible None
Retail Pharmacy
- Tier 1A / Tier 1B $5 / $15 Copay
- Tier 2 $30 Copay
- Tier 3 $50 Copay
- Tier 4 30% up to $250
- Supply Limit 30 Days
Mail Order Pharmacy
- Tier 1A / Tier 1B $12.50 / $37.50 Copay
- Tier 2 $90 Copay
- Tier 3 $150 Copay
- Tier 4 30% up to $250
- Supply Limit 90 Days
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