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%	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%	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then 20%
Lumenos HSA 5000 Deductible	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	Deductible, then 100%	Deductible, then 100%	Deductible, then 100%	Deductible, then $15/$40/$60/30%
Classic HMO	$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	Not Covered	Deductible & Coinsurance	Deductible & Coinsurance	$15 copay generic only
Hospital Benefits Plus	50%	Deductible & Coinsurance	Deductible & Coinsurance	$15 copay generic only
Hospital Benefits Preferred	50%	Deductible & Coinsurance	Deductible & Coinsurance	$15 copay generic only
PPO $35 Copay Gen Rx	$35	$500 + 30%, $3500 max	$500 + 30%, $3500 max	$15 generic only
Lumenos HSA 3000 Deductible	Deductible, then 0%	Deductible, then 0%	Deductible, then 0%	Deductible, then $15/$40/$60/30%
Classic HMO Select	$20	$500	$250	$15/$40/$60/30%
$25 Copay $2000 Ded	$25	$2000 + 20%, $5000 max	$2000 + 20%, $5000 max	$15/$30/$50/30%

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

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
Plan A	$15	$0	10% to $1K + copays
Plan I	$25	$0	20% to $2K + copays
Plan J	$25	$0	20% to $2K + copays