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

Plans Effective 8-1-10 - EMPLOYEE ELECT PLANS (Brochure)
Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

 Prescriptions

$45 Copay GenRx

$45
$750 + 40%, $4750 max
$750 + 40%, $4750 max

$15 generic only

$35 Copay GenRx
$35

$500 + 30%, $4000 max

$500 + 30%, $4000 max

$15 generic only

PPO $50/$75 Copay GenRx
$50/$75
$1500 + 40%, $6000 max
$1500 + 40%, $6000 max
$15 generic only
PPO $40/60 Copay $5000 Ded
$40/$60
$5000+30%, $8,000 max
$5000+30%, $8,000 max
$15/$40/$60/30%

PPO $30/$60 Copay
$3000 Ded

$30/$60
$3000 + 30%, $6000 max
$3000 + 30%, $6000 max
 $15/$40/$60/30%
PPO $30/$60 Copay
$2000 Ded
$30/$60
$2000 + 30%, $5000 max
$2000 + 30%, $5000 max
$15/$40/$60/30%
PPO
$25/$50 Copay $1500 Ded
$25/$50

$1500 + 20%, $4000 max
$1500 + 20%, $4000 max
 $15/$40/$60/30%
PPO
$25/$50 Copay $1000 Ded
$25/$50
$1000 + 20%, $4000 max
$1000 + 20%, $4000 max
$15/$40/$60/30%
PPO $20/$40 Copay $500 Ded
$20/$40
$500 + 20%, $3000 max
$500 + 20%, $3000 max

$15/$40/$60/30%

Lumenos HSA 3000 Deductible
Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%

Lumenos HSA 2000 Deduct. 90%

Deductible, then 10%
Deductible, then 10%
Deductible, then 10%
Deductible, then 10%

Lumenos HSA 2000 Deduct. 80%

Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Lumenos HSA 3000 Deductible 90%
Deductible, then 10%
Deductible, then 10%
Deductible, then 10%
Deductible, then 10%
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 $45 Copay
Gen Rx
$45
$750 + 40%, $4750 max
$750 + 40%, $4750 max
$15 generic only
Lumenos HSA 3000 Deductible
Deductible, then 0%
Deductible, then 0%
Deductible, then 0%
Deductible, then $15/$40/$60/30%
HMO Select $40 $1000 Ded
$40/$60
$1000+20%, $5000 max
$1000+20%, $5000 max
$15/$40/$60/30%

PPO $30/$60 $2000 Ded
$30/$59
$2000 + 30%, $5000 max
$2000 + 30%, $5000 max

$15/$40/$60/30%

Old Plans

Plans Prior to 8-1-10 - 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%


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