MEDICAL

Medical Insurance

Medical Mutual

Policy # 779308

Breakthrough Charter Schools provides you the opportunity to select basic protection through a core group of benefit programs. You may elect coverage when you first become eligible, during the annual open enrollment period, and when you experience a Qualifying Event.

You may select coverage for yourself, your spouse and/or your children depending on your family’s needs.

Resources

MMO HSA Plan SBC

MMO PPO Plan SBC

Plan Feature	PPO (In-Network)	PPO (Out-of-Network)	HSA (In-Network)	HSA (Out-of-Network)
Deductible (single/family)	$500/$1,000	$1,000/$2,000	$3,000/$6,000	$5,000/$10,000
Coinsurance	20% after deductible	40% after deductible	Deductible, then 10%	Deductible, then 30%
Out-of-Pocket Maximum (single/family)	$2,000/$4,000	$4,000/$8,000	$3,800/$7,600	$7,000/$14,000
Office Visit
Primary Care	$20	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Specialist/Urgent Care	$35/$50	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Preventive Care	No Charge	Deductible, then 40%	No Charge	Deductible, then 30%
Inpatient Services
Physician	Deductible, then 20%	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Hospital	Deductible, then 20%	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Outpatient Services
Physician	Deductible, then 20%	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Hospital	Deductible, then 20%	Deductible, then 40%	Deductible, then 10%	Deductible, then 30%
Emergency Room	$150	$150	Deductible, then 10%	Deductible, then 10%

With your medical plan, you have the option at the time of service to choose whether or not to utilize network providers. By selecting in-network providers, your costs will be lower than by using non-network providers.

* For those on the HSA plan, your school contributes $500 per year to your individual HSA account. This amount is paid out on a quarterly basis in January, April, July and October for active, eligible employees.

Prescription (Rx) Drug coverage

Medical Mutual

When filling prescriptions, you have the following copay obligations for up to a 31-day supply for retail, and up to a 90-day supply for Mail Order:

Plan Feature	PPO (In-Network)	PPO (Out-of-Network)	HSA (In-Network)	HSA (Out-of-Network)
Retail 30-Day Supply			Copays Apply After Deductible
Tier 1 (Generic)	$10 co-pay	Not Covered	$10 co-pay	Not Covered
Tier 2 (Preferred)	$30 co-pay	Not Covered	$30 co-pay	Not Covered
Tier 3 (Non-Preferred Brand)	$60 co-pay	Not Covered	$50 co-pay	Not Covered
Tier 4 (Specialty)	25% up to $250 max	Not Covered	Applicable drug tier copay applies	Not Covered
Mail-Order 90-Day Supply
Tier 1 (Generic)	2x co-pay	Not Covered	2x co-pay	Not Covered
Tier 2 (Preferred)
Tier 3 (Non-Preferred Brand)
Tier 4 (Specialty)

Please review the detailed benefit summary document for more information on the medical plans. Note: All In-Network Preventive care (coded as “preventive care” by your doctor) will be paid in full by Anthem.