Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.
Plan Descriptions
EMPLOYEE ELECT PLANS (Brochure)
Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Prescriptions

PPO $30 Copay

$30
$500 + 20%, $3500 max
$500 + 20%, $3500 max
$15/$30/$50/30%
PPO $30 Copay $3000 Ded.
$30
$3000+20%, $8000 max
$3000+20%, $8000 max

$15/$30/$50/30%

PPO $40 Copay
$40
$500 + 30%, $4000 max
$500 + 30%, $4000 max
$15/$30/$50/30%
PPO $40 Copay $5000 Ded
$40
$5000+30%, $13,000 max
$5000+30%, $13,000 max
$15/$30/$50/30%

PPO $35 Copay
Gen Rx

$35
$500 + 30%, $3500 max
$500 + 30%, $3500 max
$15 generic only
PPO $45 Copay
Gen Rx
$45
$750 + 40%, $4000 max
$750 + 40%, $4000 max
$15 generic only
Premier PPO
$15 Copay
$15
$150 + 10%, $2500 max
$150 + 10%, $2500 max
$10/$30/$50/30%
Premier PPO
$25 Copay
$25
$150 + 20%, $3000 max
$150 + 20%, $3000 max
$15/$30/$50/30%
PPO $25 Copay $2000 Ded
$25
$2000 + 20%, $5000 max
$2000 + 20%, $5000 max

$15/$30/$50/30%

Lumenos HSA 2000 Deductible

Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%

Lumenos HSA 2000 Deduct. 80% 1

Deductible, then 100%
Deductible, then 100%
Deductible, then 100%
Deductible, then 20%
Lumenos HSA 3000 Deductible
Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%
Lumenos HSA 3000 Deduct. 80% 1
Deductible, then 100%
Deductible, then 100%
Deductible, then 100%
Deductible, then 20%
Lumenos HSA 5000 Deductible A
Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%
Lumenos HIA Plus 2000 Deductible
Deductible, then 100%
Deductible, then 100%
Deductible, then 100%
Deductible, then $15/$40/$60/30%
Lumenos HIA Plus 3000 Deductible A
Deductible, then 100%
Deductible, then 100%
Deductible, then 100%
Deductible, then $15/$40/$60/30%
Classic HMO A
$20
$500
$250
$15/$40/$60/30%
Classic HMO Select
$20
$500
$250
$15/$40/$60/30%
HMO Select $45 Copay
$45
Deductible then 40%
Deductible then 40%
$15 copay generic only
HMO Select $40 Copay
$40
Deductible then 30%
Deductible then 30%
$15/$40/$60/30%
PPO Exclusions        
HMO Exclusions        

BENEFITS PLANS (Brochure)

Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Prescriptions
Hospital Benefits A

Not Covered

Deductible & Coinsurance
Deductible & Coinsurance
$15 copay generic only
Hospital Benefits Plus A
50%
Deductible & Coinsurance
Deductible & Coinsurance
$15 copay generic only
Hospital Benefits Preferred A
50%
Deductible & Coinsurance
Deductible & Coinsurance
$15 copay generic only

PPO $35 Copay
Gen Rx
A

$35
$500 + 30%, $3500 max
$500 + 30%, $3500 max
$15 generic only
Lumenos HSA 3000 Deductible AA
Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%
Classic HMO Select b
$20
$500
$250
$15/$40/$60/30%
$25 Copay $2000 Ded
$25
$2000 + 20%, $5000 max
$2000 + 20%, $5000 max

$15/$30/$50/30%



State Mandated Plans

 

Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Basic HMO
$40/$60

$500/day, max $2000

$300
Standard HMO $25/$40 $250/day, max $1000

$150

Basic PPO $40/$60

$4000 deductible + 30%, $8000 max

$4000 deductible + 30%, $8000 max

Standard PPO $25/$40
$1500 deductible + 20%, $3500 max
$1500 deductible + 20%, $3500 max


Discontinued Plans

The following plans were discontinued by Anthem as of 10-31-05.  Some plans may be renewed in 2006, other plans will
have to be converted to a new plan design.  Please call (303) 721-1145 for details.

 

BluePreferred PPO Plans

Plan Name
Office Visit Copay
Deductible
Coinsurance
$15
$0
10% to $1K + copays
$25
$0
20% to $2K + copays
$25
$0
20% to $2K + copays