Infopro Learning Employee Benefits - Benefits Plan Summary

Plans

CARRIER / TPA
NETWORK
PLAN TYPE
DEDUCTIBLE
IN NETWORK
PCP COPAY
SPECIALTY CARE COPAY
PREVENTIVE CARE
URGENT CARE
XRAY
LABS-DIAGNOSTIC
LABS - MRI, CAT, XRAY
COINSURANCE
DEDUCTIBLE (S/F)
MAX OUT OF POCKET (S/F)
HOSPITAL IN-PATIENT
HOSPITAL OUT-PATIENT
ER COPAY
LIFETIME MAXIMUM
OUT OF NETWORK
DEDUCTIBLE
COINSURANCE
MAXIMUM OUT OF POCKET
LIFETIME MAXIMUM
RX BENEFIT
TIER 1 / 2 / 3 (Gen / Br / Nf / Spec) GENERIC / BRANDED / NON FORMULARY / SPECIALTY
RX DEDUCTIBLE
MONTHLY PREMIUM
EMPLOYEE
EMPLOYEE (Pay Rate < = $22)
EMPLOYEE / SPOUSE
EMPLOYEE / CHILD
EMPLOYEE / FAMILY

GOLD

Anthem BCBS / Leading Edge Administrators (LEA)
National PPO (BlueCard PPO)
PPO
Calendar Year
$25
$50
100%
$50
Office Setting or Independent Lab $25 copay/visit, Facility based Services: 15% Coinsurance after Deductible.
Office Setting or Independent Lab $25 copay/visit, Facility based Services: 15% Coinsurance after Deductible.
Office Setting or Independent Lab $25 copay/visit, Facility based Services: 15% Coinsurance after Deductible.
85% (Reduced)
$3,500 / $7,000
$6,000 / $12,000
Ded & Co-ins
Ded & Co-ins
$250
Unlimited
$6,000 / $12,000
70%
$10,000 / $20,000
Unlimited
30 Day Supply: $10/$25/$50
Mail / Retail order up to 90 Days' Supply : $25 / $50 / $125
Specialty: Contact Payer Matrix for
assistance at 1-877-305-6202
9am - 7:30pm EST M-F
-
$475.00
$475.00
$900.00
$800.00
$1,450.00

SILVER

Anthem BCBS / Leading Edge Administrators (LEA)
National PPO (BlueCard PPO)
HSA
Calendar Year
Ded & Co-ins
Ded & Co-ins
100%
Ded & Co-ins
Ded & Co-ins
Ded & Co-ins
Ded & Co-ins
80% (Reduced)
$5,000 / $7,500
$7,500 / $12,000
Ded & Co-ins
Ded & Co-ins
Ded & Co-ins
Unlimited
$6,000 / $12,000
50%
$10,000 / $20,000
Unlimited
30 Day Supply: $10/$35/$70
Mail / Retail order up to 90 Days' Supply: $25/$87.50/$175
Specialty: Contact Payer Matrix for
assistance at 1-877-305-6202
9am - 7:30pm EST M-F
-
$295.00
$99.00
$725.00
$650.00
$950.00

DENTAL

VISION

Benefits Plan Summary