Page 9 - American Business Bank EE Guide 01-19 - C2

Medical Insurance

Blue Shield Blue Shield
PPO HSA PPO

Network Network Non-Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $750 $1,500 $3,000
- Family Member / Family $750 / $1,500 $1,500 / $3,000 $3,000 / $6,000
Out-of-Pocket Maximum
- Individual $5,250 $9,500 $5,500 $10,000
- Family Member / Family $5,250 / $10,500 $9,500 / $19,000 $5,500 / $11,000 $10,000 / $20,000
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Specialist Office Visit $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Urgent Care $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Teladoc $5 Copay N/A $5 Copay* N/A
Hospitalization
- Inpatient Deductible, Deductible, 40%** Deductible, Deductible, 40%**
$100 Copay, 20% $100 Copay, 20%
- Outpatient Surgery Deductible, 10% - 25% Deductible, 40%** Deductible, 10% - 20% Deductible, 40%**
Diagnostic Lab and X-Ray
- Advanced Imaging Deductible, 20% Deductible, 40%** Deductible, Deductible, 40%**
$100 Copay, 20%
- All Other Lab and X-Ray Deductible, Deductible, 40%** Deductible, Deductible, 40%**
$25 - $50 Copay $25 Copay, 20%

Emergency Services Deductible, $150 Copay, 20% Deductible, $150 Copay, 20%
Chiropractic / Acupuncture Deductible, $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
(Ded waived for Chiro)

Chiropractic: 20 Visits/Year Chiropractic: 20 Visits/Year
Acupuncture: 20 Visits/Year Acupuncture: 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible None None Plan Deductible Applies
Retail Pharmacy
- Generic / Tier 1 $15 Copay $15 Copay + 25% $10 Copay $10 Copay + 25%
- Brand Name / Tier 2 $30 Copay $30 Copay + 25% $25 Copay $25 Copay + 25%
- Non-Formulary / Tier 3 $45 Copay $45 Copay + 25% $40 Copay $40 Copay + 25%
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic / Tier 1 $30 Copay Not Covered $20 Copay Not Covered
- Brand Name / Tier 2 $60 Copay Not Covered $50 Copay Not Covered
- Non-Formulary / Tier 3 $90 Copay Not Covered $80 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
*Once the deductible has been met, Teladoc Services will be a $5 copay.
**Limits apply for non-network services. See SBC for details.

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