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education on how to better manage your condition
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www.anthem.com and select Health & Wellness.
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a i
t o
i n
o .
n

- 13 -

MEDICAL INSURANCE

LIV
I E
V HEA
E L
A T
L H
T
H ONL
N I
L N
I E
N

Wh
W a
h t
a
t i s
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O l
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e ?
®
?
Use LiveHealth Online for common health concerns like colds, the flu,
fevers, rashes, infections, allergies and more! It’s faster, easier and more
convenient than a visit to an urgent care center.

LiveHealth Online is part of your health plan benefits. The cost of a LiveHealth Online visit is the same or
less than a primary care office visit. With LiveHealth Online, you have a doctor by your side 24/7.
LiveHealth Online lets you talk face-to-face with a doctor through your mobile device or a computer with a
webcam. No appointments, no driving and no waiting at an urgent care center.

Ho
H w
o
w d
o
d e
o s
e
s L
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L v
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o
w r
o k
r ?
k
?
When you need to see a doctor, simply go to livehealthonline.com or access the LiveHealth Online mobile
app. Select the state you are located in and answer a few questions. Best of all, LiveHealth Online is a part
of your health plan. So, the cost of a LiveHealth Online visit is the same or less than a primary care office
visit. Establishing an account allows you to securely store your personal and health information. Plus, you
can easily connect with doctors in the future, share your health history and schedule online visits at times
that fit your schedule. Once connected, you can talk and interact with the doctor as if you were in a private
exam room.

Ho
H w
o
w d
o
d
o I

I a
c
a c
c e
c s
e s
s
s L
i
L v
i e
v H
e e
H a
e l
a t
l h
t
h O
n
O l
n iln
i e
n ?
e
?
Sign up at LiveHealthOnline.com
or
Download the LiveHealth Online mobile app for free on your mobile device by visiting the App StoreSM or
Google PlayTM.

Ho
H w
o
w d
o
d
o I

I p
a
p y
a
y f
o
f r
o
r a

a L
i
L v
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v H
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H a
e l
a t
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t
h O
n
O l
n iln
i e
n
e s
e
s s
e s
s i
s o
i n
o ?
n
?
LiveHealth Online accepts Visa, MasterCard and Discover cards as payment for an online visit with a doctor.
Please keep in mind that charges for prescriptions aren’t included in the cost of your doctor’s visit.

Do
D
o d
o
d c
o t
c o
t r
o s
r
s h
a
h v
a e
v
e a
c
a c
c e
c s
e s
s
s t
o
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y
m
y h
e
h a
e l
a t
l h
t
h i n
i f
n o
f r
o m
r a
m t
a i
t o
i n
o ?
n
?
LiveHealth Online doctors can only access your health information and review previous treatment
recommendations and information from prior LiveHealth Online visits.

If you are using LiveHealth Online for the first time, you will be asked to answer a brief questionnaire about
your health before you speak with a doctor. Then the information from your first online visit will be
available for future LiveHealth Online visits.

Wh
W o
h
o d
o
d
o I

I g
e
g t
e
t i n
i
n t
o
t u
o c
u h
c
h w
i
w t
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t
h i f
i
f I

I s
t
s i
t lill lh
a
h v
a e
v
e q
u
q e
u s
e t
s i
t o
i n
o s
n ?
s
?
You can email, customersupport@livehealthonline.com or call toll free at 1-855-603-7985.

If you send us an email, please be sure to include:

Your name

Your email

A phone number where you can be reached

LiveHealth Online should not be used for emergency care. If you experience a medical emergency, call 911
immediately.



- 14 -

MEDICAL INSURANCE


Future Moms

The program, Future Moms, is there for our moms-to-be. At such an important time in your life, you’ll have

access to extra pre- and post-natal, confidential support and education any time of the day or night! Even with

terrific care from your doctor, you may have questions that come up between visits. Nurses are available for you

to talk with around the clock. You may also benefit from:

Ma
ternity care materials including Your Pregnancy Week By Week, which is a helpful prenatal care book, free
for
just enrolling in the plan

A confidential questionnaire to evaluate your risk for premature delivery

Us eful tools to help you, your doctor and your Future Moms nurse track your pregnancy and identify possible
ris ks

Anthem’s goal is to help you and your doctor work together to have a healthy pregnancy and a healthy new baby.
Remember, your doctor is your best source of information about your pregnancy and your health, and Future
Moms is here to help along the way.
To reach Future Moms, call toll-free 1-800-828-5891 or go to www.anthem.com and select Health & Wellness

24/7 NurseLine
Whether it’s 3 p.m. or 3 a.m., wouldn’t it be great if you could speak with an experienced nurse about any of your
health questions or issues? Now you can!

The 24/7 NurseLine can assist you in making more informed health care decisions via confidential, one-on-one
conversations with a registered nurse, any time of the day or night. Whenever you call, you can easily access a
library of audio tapes on a range of topics related to your health care. Or, if you prefer, you can talk to a nurse
about hundreds of health issues ranging from asthma to zinc, like: Coughs Abdominal Pain Weight Loss Colds
Children’s Health Sexually Transmitted Diseases . Fever Food & Diet Headache Smoking Women’s Health .
. . and much more! Bilingual nurses, the Language Line and TTY/TDD relay services for the hearing impaired are
also available.

For confidential health information from a registered nurse 24-hours a day, 365 days a year, call 1-800-337-4770
or go to www.anthem.com and select Health & Wellness.

24/7 NurseLine is not an emergency response system. In a medical emergency, call 911 or your local emergency
service number.
To reach 24/7 NurseLine, call toll-free 1-800-337-4770 or go to www.anthem.com and select Health & Wellness.
Colorado QuitLine
Whether you are thinking about quitting tobacco or have already quit, Colorado QuitLine is a FREE program and
here to help you. Join QuitLine today and receive free:

Personally tailored quit program
Nicotine replacement therapy
Support network
Telephone coaching
Tools and tips based on the latest research

Website: .................................................................................................................... www.coquitline.org
Phone: .............................................................................................................................. 1-855-891-9988
- 15 -

MEDICAL INSURANCE


The CHEIBA Trust and the CHEIBA Trust Members offer you four medical insurance plans from which to select.

There is a fifth plan (Custom Plus), but it is closed to new enrollment. Please carefully review the Multi-Option

Plan Summary located in the pocket of this booklet regarding the various medical insurance plans before you

make your selection. After you enroll, you will receive your membership card. It will be mailed to your home.

If you do not receive your card, call the Customer Service number as noted on the Plan Contacts Page at the

beginning of this book.

ANT
N H
T E
H M
E BLU
L E
U
E CRO
R S
O S
S
S A
N
A D
N
D BLU
L E
U SHI
H E
I L
E D
L /H
/ M
H O
M COL
O O
L R
O A
R D
A O
D

Yo
Y u
o r
u
r c
ho
h i
o c
i e
c s
s in
i c
n l
c u
l d
u e
d :



Provided by HMO

Preferred Provider
BlueAdvantage
Prime Blue
Colorado
Organization, PPO

Point of
Priority PPO
(HMO/POS)

Service Plan
Plan







New for 2016
Lumenos High
New for 2016
Blue Priority

Deductible
HMO Plan

Health Plan



Custom Plus Health Plan is closed to new enrollment.

Premium Payments
To assist in reducing your insurance premium costs, your share of medical insurance premiums can be paid
with pre-tax dollars under the CHEIBA Trust Pre-Tax Insurance Premium Payments Account under the
Flexible Benefit Plan. If you and your spouse both work within the CHEIBA Trust system and choose the
Dependent coverage option, you may choose to have one spouse pay for all premiums. If you and your
spouse both work within the CHEIBA Trust system and Dependent coverage is not selected, you should
enroll separately to maximize premium savings.

For Premium Payments involving Domestic Partners and the children of Domestic Partners, please review
the document titled, “Important Tax Information for Domestic Partners - Medical and Dental Benefits”. See
summary of Domestic Partner Benefits on page 5 for further information.

For Premium Payments involving Civil Union Partners and the children of Civil Union Partners, please review
the document titled, “Important Tax Information for Partners in a Civil Union – Medical, Dental and Term
Life Benefits”.

NOTE: If you are a Participant in PERA and are within three years of retirement, you may want to elect to
pay your premiums with after-tax dollars to ensure your highest possible PERA benefit in retirement.


PERA retirement benefits are based on your highest average salary. Please contact your Human
Resources/Benefits Office for additional information.
- 16 -

MEDICAL INSURANCE


BLU
L E
U ADV
D A
V N
A T
N A
T G
A E
G HM
H O
M /
O P
/ O
P S
O
PRI
R M
I E
M
E BL
B U
L E
U
E P
R
P I
R O
I R
O I
R T
I Y
T
Y PP
P O
P
This choice is the Point-of-Service (HMO/POS) Plan which includes
This choice is a flexible plan option that al ows you access to three
both in-network and out-of-network benefits. A member has the option
different levels of providers, each with different out-of-pocket costs:
for both in-network and out-of-network benefits based on the provider

rendering the service.

Level 1: Blue Priority Designated providers are either PCP’s or

specialists. A Designated PCP or Designated specialist has the
Services rendered by a non-HMO provider are processed under the
lowest out-of-pocket costs. Blue Priority Designated providers
POS benefits and are subject to the applicable deductible and
are located in the following counties - Adams, Arapahoe,
coinsurance. This option is designed to give HMO members the choice
Boulder (including Longmont), Broomfield, Denver, Douglas,
to use a non-HMO provider and stil receive a level of benefits. A
Elbert, El Paso, Fremont, Jefferson, La Plata, Montezuma,
referral from your HMO primary care provider is not needed to seek
Pueblo, Summit and Tel er.
services from a non-HMO provider.


Level 2: Providers in Anthem’s large, traditional PPO network
Additionally, out-of-network services may be subject to Balance
may serve as PCP’s and specialists, but with higher out-of-pocket
Billing. If you have any questions regarding out-of-network services,
costs to you because they are not Designated providers.
please read the plan description careful y or cal for assistance.

Level 3: Nonparticipating providers are at the highest out-of-
pocket costs.

NOTE: If you live in a rural area and there are no PPO

providers within a reasonable distance from you, you may

request authorization to see an out-of-network provider and

benefits wil be applied at the in-network level. Cal customer

service to request the authorization.

Additionally, out-of-network services may be subject to Balance
Billing. If you have any questions regarding out-of-network services,
please read the plan description careful y or cal for assistance.

Ph
P y
h s
y i
s c
i i
c a
i n
a
n Se
S l
e ec
e t
c i
t on
o
You must select a primary care physician (PCP) for yourself and each
You must select a Blue Priority Designated primary care physician
covered Dependent in order to be eligible for in-network benefits. You
(PCP) for yourself and each covered Dependent. However, you may
have the right to designate any primary care provider who participates
receive care from any provider that participates in the network. You wil
in the network and who is available to accept you or your family
pay less if you receive care from a Designated provider.
members. For children, you may designate a pediatrician as the

primary care provider.
Members are not required to obtain referrals from their PCP to see an

in-network specialist.
Members are not required to obtain a referral from their PCP to see an
in-network specialist. However, Anthem does encourage you to ask
your PCP for an in-network referral recommendation.

For information on how to select a primary care provider and for a list
of the participating primary care providers and participating health care
professionals, who specialize in obstetrics or gynecology, contact
Anthem Blue Cross Blue Shield at 1-800-542-9402 or
www.anthem.com/.

Ho
H w
o
w t
o
t
o f
i
f n
i d
n
d a

a P
C
P P
C
P o
r
o
r o
t
o h
t e
h r
e
r pr
p o
r v
o i
v d
i e
d r
e s
r
Go to www.anthem.com and select Find A Doctor:
Go to www.anthem.com and select Find A Doctor:



Select a state:

Select a state:

Select a plan/network: HMO

Select a plan/network: PPO*

Choose Select and Continue

Choose Select and Continue

Complete fields for provider type, specialty and location

Complete fields for provider type, specialty and location

Select: Search

Select: Search

* To search for a Designated Blue Priority Tier 1 provider,
please use the Blue Priority PPO network.

- 17 -

MEDICAL INSURANCE

BL
B U
L E
U
E P
R
P I
R O
I R
O I
R T
I Y
T
Y H
M
H O
M
O
LU
L M
U E
M N
E O
N S
O
S H
I
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I H
G
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E
D D
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D C
U T
C I
T BL
B E
L
E H
E
H A
E L
A T
L H
T
H P
L
P A
L N
A
This choice is the Blue Priority HMO Plan which includes in-network
This choice is a Preferred Provider (PPO) plan option which includes in
benefits only.
and out-of-network coverage.


Members must choose a primary care physician from the Blue Priority
Members must pay their annual deductible* during the plan year before
network. Providers are located in the Denver metro area, which
the plan helps pay for costs. This includes costs for medical and
includes Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and
prescription drug expenses. Al in-network preventive care services are
Jefferson counties, as wel as Elbert, El Paso, Tel er, Fremont, La
100% covered.
Plata, Montezuma, Pueblo, Summit counties and the city of Longmont.


In-network doctors have a pre-negotiated rate with Anthem Lumenos,
Your primary care physician is your personal provider who coordinates
so your expenses wil be less if you use in-network doctors.
your care within the Blue Priority HMO network. Referrals to see a

specialist are required.



Example: If you go to the doctor for a sore throat before you

meet the deductible, you pay the ful (negotiated) cost of the

office visit and any tests your physician orders and prescription
drugs prescribed. However, if you see an out-of-network

doctor, your out-of-pocket expenses may be greater.

This plan can be combined with a health savings account (HSA) to
al ow you to pay for qualified, out-of-pocket medical expenses on a pre-
tax basis. An HSA account is a personal, portable account and remains
in your control regardless of your employment. An HSA can be
established through any qualifying financial institution. Please contact
your financial advisor or banking institution for additional
information.
* The annual deductible under the Lumenos HDHP is non-embedded.
For employees with dependents, this means that al family members’
out-of-pocket expenses count toward the family deductible until it is
met. It does not matter if one person incurs al the expenses that meet
the deductible or if two or more family members contribute toward
meeting the family deductible.

Ph
P y
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y i
s c
i i
c a
i n
a
n S
e
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You must select a Blue Priority primary care physician (PCP) for
You can select PPO physicians who have entered into an agreement
yourself and each covered Dependent in order to be eligible for in-
with Anthem Blue Cross and Blue Shield to provide care at negotiated
network benefits. You have the right to designate any Blue Priority
rates, or you may select the physician of your choice outside of the
primary care provider who participates in the network and who is
PPO network. However, out-of-pocket expenses may be significantly
available to accept you or your family members. For children, you may
higher if you select and out-of-network provider.
designate a pediatrician as the primary care provider.

Members are required to obtain a referral from their PCP to see an in-
network specialist.

Ho
H w
o
w t
o
t
o f
i
f n
i d
n
d a

a P
C
P P
C
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o
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h r
e
r p
r
p o
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o i
v d
i e
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r
Go to www.anthem.com and select Find A Doctor:
Go to www.anthem.com and select Find A Doctor:



Select a state:

Select a state:

Select a plan/network: Blue Priority HMO

Select a plan/network: Lumenos PPO

Choose Select and Continue

Choose Select and Continue

Complete fields for provider type, specialty and location

Complete fields for provider type, specialty and location

Select: Search

Select: Search


- 18 -

MEDICAL INSURANCE

PRE
R S
E C
S R
C I
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I T
P I
T O
I N
O
N D
R
D U
R G
U
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t PP
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O
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y H
M
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M an
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D
H H
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Your ID Card is your membership card for both doctor visits and prescriptions. The prescription drug benefit is provided through Anthem's
Pharmacy Benefits Manager (PBM) and includes a formulary plan with four tiers:


Tier 1 Generics - these drugs are simply copies of brand-name drugs. Brand-name and generic drugs have the same active
ingredients, strength and dose. The FDA requires that generic drugs meet the same high standards for purity, quality, safety and
strength. With generics, you get the same quality for less money.

Tier 2 Preferred Brand - these are drugs for which generic equivalents are not available. They have been in the market for a time and
are widely accepted. They cost more than generics, but less than non-preferred brand-name drugs.

Tier 3 Non-Preferred Brand - these drugs are general y higher-cost medications that have recently come on the market. In most cases,
an alternative preferred or generic medication is available.

Tier 4 Specialty Drugs - these are prescription medications used to treat complex, chronic conditions that may require special handling
and/or management. It is important to note the fol owing:

o
Not al specialty drugs on Tier 4 are subject to the Tier 4 coinsurance. For example, capecitabine, a drug used to treat cancer,
is generic so a member could obtain this prescription for the Tier 1 copayment.

o
Some specialty drugs are considered Retail Pharmacy Drugs and are not on the Exclusive Specialty List. These drugs are not
required to be obtained through the specialty pharmacy. An example of this would be Arixtra, a drug used to prevent blood
clots.

The formulary includes prescription drugs that have been approved for use by HMO Colorado and is updated on a quarterly basis. You can
review this formulary by going to www.anthem.com/.


NOTE: Prescription drugs wil always be dispensed as ordered by your provider and by applicable State Pharmacy Regulations, however,
you may have higher out-of-pocket expenses. You may request, or your provider may order, the brand-name drug. However, if a generic
drug is available, you wil be responsible for the cost difference between the generic and brand-name drug, in addition to your Tier
copayment. The cost difference between the generic and brand-name drug does not contribute to the out-of-pocket annual maximum. (Tier
1 generic copayment is not applicable if you are enrol ed in the Lumenos HDHP)

Diabetic supplies/prescriptions and asthma inhalers/prescriptions wil be covered at no cost to you.
Members taking specialty drugs must order them through Accredo at 1-800-870-6419, which offers a ful -service pharmacy that ships
medications to members or their provider, up to a 30-day supply, by overnight mail or common carrier.
Mail Order/Home Delivery: If you need maintenance medications for ongoing conditions such as asthma, diabetes, high blood pressure, etc.,
you may want to use home delivery service. This service offers you the convenience of having prescriptions delivered directly to the home, office
or anywhere in the United States. Ordering your maintenance medications through home delivery eliminates monthly trips to the pharmacy and
al ows you to receive more days’ supply with fewer copayments. Typical savings are at least one copayment for each prescription.

Prescription drugs purchased from out-of-network pharmacies are not covered.


Call Customer Service at: ...................... 1-800-542-9402
If you have questions
or
Go to the website: ............................ www.anthem.com





- 19 -

MEDICAL INSURANCE


CU
C S
U T
S O
T M
O PL
P U
L S
U HE
H A
E L
A T
L H
T PL
P A
L N
A


Closed to new enrollment effective January 1, 2010.

This is a traditional major medical plan.

Physician Selection
There are no restrictions regarding the choice of physicians under this plan. Please note, if you select a
provider not participating in the Traditional Participating Network, you may be subject to Balance Billing.

Prescription Drug Benefit
Prescription drugs are covered at 80% after the deductible is met. There is no separate prescription card.
Prescription benefits are reimbursed to you after you submit a medical expense claim form found on
www.anthem.com. Claim forms are provided through Anthem Blue Cross and Blue Shield of Colorado or
through your Human Resources/Benefits Office.
Medical Benefits
Custom Plus
Description
No Defined Network
$600 Individual
Annual Deductible
$1,200 Family
Individual deductible plus $2,000
Annual Maximum Out-of-Pocket
Family deductible plus $4,000
Physician Selection
Unrestricted; greater benefits with Traditional Participating Network provider
Physician Services
80% after deductible (based on the maximum benefit allowance)
Hospital
80% after deductible (based on the maximum benefit allowance)
Outpatient Surgery
80% after deductible (based on the maximum benefit allowance)
Outpatient Lab
80% after deductible (based on the maximum benefit allowance)
Prescriptions
80% after deductible
Retail & Mail Order

If you want to complete your enrollment forms, review the Multi-
Option Plan Summary or review this Benefit Booklet, reference
Custom Plus
this plan name:
If you want to search for information (like searching for a doctor)
Major Medical/ Traditional Provider Network
on the anthem.com website, reference this plan name:
Call Customer Service at: ...................... 1-800-542-9402
If you have questions
or
Go to the website: ............................ www.anthem.com


NOTE: The following chart is only an overview of your insurance plan choices. Review the Multi-Option
Plan Summary (back pocket of this book) and the specific certificate booklets pertaining to each plan for
further details and explanations. If discrepancies are found, depend upon the certificate of coverage itself
for accuracy.
- 20 -

MEDICAL INSURANCE

BlueAdvantage
PRIME Blue Priority PPO
Blue Priority HMO
Lumenos PPO
Description
In Network
Non-PPO Out of
Out of Network (POS)
PPO In Network
HMO In Network Only
PPO In Network
Non PPO Out of Network
(HMO)
Network
$2,000 Individual
$6,000 Family
$500 Individual
$400 Individual
$960 Individual
$2,500 Individual
$2,500 Individual
Annual Deductible
None
Plus $200 Deductible per individual or
$1,000 Family
$800 Family
$1,920 Family
$5,000 Family
$5,000 Family
$400 per family for outpatient tier 2 & tier 3
Prescription Drugs
Individual deductible
Individual deductible
Out-of-Pocket Annual
$2,000 Individual
plus $2,500
Individual deductible plus $750
plus $2,000
$4,000 Individual
$2,500 Individual
$5,000 Individual
Maximum
$4,000 Family
Family deductible plus
Family deductible plus $1,500
Family deductible plus
$10,000 Family
$5,000 Family
$10,000 Family
$5,000
$4,000
Individual-
Individual- Deductible,
Copayments for inpatient hospital,
Copayments,
Individual- Deductible
Coinsurance &
outpatient surgery & other outpatient
Deductible and
Individual-Coinsurance.
& Coinsurance
Copayments.
Out of Pocket Annual
services except emergency room
Deductible is NOT
Coinsurance.
Copayments, Deductible,
Family (Non-Single)-Copayments,
Family (Non-single)-
Family (Non-single)-
Maximum Includes
copayments. Al other copayments
included.
Family (Non-Single)-
Coinsurance
Deductible and Coinsurance.
Deductible &
Deductible,
are stil required after the out-of-
Copayments,
Coinsurance
Coinsurance &
pocket annual maximum is met.
Deductible and
Copayments.
Coinsurance.
Physician Selection
PCP required
Unrestricted
PCP required
Unrestricted
PCP required
Unrestricted
Unrestricted
Designated Participating
Providers: $10 copayment per
Physician Services
$20 copayment per visit
70% after deductible
65% after deductible
$20 copayment per visit
100% after deductible
70% after deductible
visit. Participating Providers: 15%
after deductible per visit
$250 copayment, then 20% after
Inpatient Hospital
$400 copayment
70% after deductible
85% PPO
65% after deductible
100% after deductible
70% after deductible
deductible
$85 copayment at a hospital-
PPO: 85% after deductible at a
$250 Copayment at an ambulatory
based facility or $60 copayment
hospital-based facility; 90% after
surgery center.
Outpatient Surgery
70% after deductible
65% after deductible
100% after deductible
70% after deductible
at a free-standing, non-hospital-
deductible at non-hospital-
$250 Copayment, then 20% after
based facility
based facility
Deductible at a Hospital.
Lab - 100% covered except those services
received from either a Hospital or
Lab & x-ray - 85% after
Hospital-based Provider.
deductible at a hospital-based
X-ray - $60 Copayment except those
facility; 90% after deducible at a
services received from either a
Lab & x-ray - 100% covered
non-hospital-based facility.
Hospital or Hospital-based Provider.
MRI/MRA/CT/PET scans - $100
MRI/MRA/ CT/PET scans: 85%
MRI/MRA/ CT/PET scans - $250
Outpatient Lab
copayment at a hospital-based
70% after deductible
65% after deductible
100% after deductible
70% after deductible
after deductible at a hospital-
Copayment except for services
facility; $80 copayment at a non-
based facility; 90% after
received from either a Hospital or
hospital-based facility
deductible at non-hospital-
Hospital-based Provider.
based facility; not subject to
$250 Copayment then 20% after
deductible and coinsurance
Deductible for services received from
either a Hospital or Hospital-based
Provider.
Tier 1-$15
Tier 1-$15
Tier 1 $15
Prescriptions
Tier 2-$30
Tier 2-$30
Tier 2 $40
Not Covered
Not Covered
100% after deductible
70% after deductible
Retail (30-day supply)
Tier 3-$45
Tier 3-$45
Tier 3 $60



Tier 1-$15
Tier 1-$15
Tier 1 $15
Mail Order
Tier 2-$30
Not Covered
Tier 2-$30
Not Covered
Tier 2 $80
100% after deductible
Not covered
(90-day supply)
Tier 3-$45.
Tier 3-$45.
Tier 3 $120
Specialty Drugs *
30% coinsurance to max $125
Not Covered
30% coinsurance to max $250
Not Covered
30% coinsurance to max $500
100% after deductible
Not covered
(30-day supply)
* Not all specialty drugs on Tier 4 are subject to the Tier 4 coinsurance. Certain specialty drugs may be subject to the Tier 1, 2 or 3 copayment.
- 21 -