Behavior Frontiers offers five choices of medical insurance plans, two HMO plans, two PPO plans, and one High Deductible Health Plan (HDHP). Each of our medical insurance plans offer different levels of deductibles, copayments, and out-of-pocket maximums. MEDICAL
Anthem PPO Plans When you enroll in either of the Anthem PPO plans, you are free to seek medical care from both in and out-of-network providers. There is no requirement that you select a PCP or receive PCP-authorized referrals to specialists. To receive the highest level of coverage under the plan, simply obtain care from an in-network provider.
Classic PPO Plan
Solution PPO Plan
Out-of-Network 1
Out-of-Network 1
In-Network
In-Network
$500 single $1,500 family
$1,500 single $3,000 family
$4,500 single $9,000 family
$1,500 single $4,500 family $12,000 single $24,000 family
Calendar Year Deductible
$4,000 single $8,000 family
$5,000 single $10,000 family
$15,000 single $30,000 family
Calendar Year Out-of-Pocket Maximum
40% after deduct ible
Physician Office Visit
$30 copay
40% after deductible
$20 copay
40% after deduct ible
Specialist Office Visit
$50 copay
40% after deductible
$40 copay
40% after deduct ible
LiveHealth Online
No charge
No charge
No charge
Preventive Care
No charge
40% after deductible
No charge
No charge
40% after deduct ible
Urgent Care
$30 copay
40% after deductible
$20 copay
40% after deduct ible
Diagnostic X-Ray/Lab
20% after deductible
40% after deductible
20% after deductible
40% after deductible, benefit limited to $350 max per visit 40% after deductible, ben- efit limited to $1,000 max per day 2
40% after deduct ible
Outpatient Surgery
20% after deductible
20% after deductible
40% after deduct ible
Inpatient Hospital
20% after deductible
20% after deductible
Emergency Room (Waived if Admitted) Retail Prescriptions Generic (Tier 1a/1b) Preferred (Tier 2) Non- Non-Preferred (Tier 3) Specialty (Tier 4)
$150 copay, then 20% after deductible
$150 copay, then 20% after deductible
30-day supply $5/$15
30-day supply $5/$20
30-day supply All tiers: 50% up to $250
30-day supply All tiers: 50% up to $250 max
$30 $50 30% up to $250 max
$40 $60 30% up to $250 max
Copays and coinsurance percentages shown in the above plan descriptions represent the amount paid by the member. 1. Members are responsible for all charges above Anthem’s allowable amounts when using non -network providers. 2.Additional $500 copay required if you do not receive preauthorization from Anthem for non-emergency visit
Behavior Frontiers Benefits Guide | 5
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