僱員申請書-Anthem.PDFVIP

2 50 EmployeeElect Anthem Blue Cross Anthem Blue Cross Life and Health Insurance Company /ca / 1a. o Premier PPO $10 Copay* o Solution 2500 PPO** o Lumenos HSA 2000 (100/70)** o HMO $10 100%* o Lumenos HSA 1500 (100/70)** HMO o Premier PPO $20 Copay* o Solution 3500 PPO** o Lumenos HSA 3000 (100/70)** o HMO $25 100%* o Advantage PPO $25 Copay** 3 o Premier PPO $30 Copay* o Solution 5000 PPO** o Lumenos HSA 5000 (100/70)** o Classic $20 HMO* o Saver PPO ** o PPO $20 Copay** o Elements Hospital Preferred** o Lumenos HSA 1500 (80/50)** o Classic $30 HMO* o Basic PPO ** * Anthem Blue Cross o PPO $30 Copay* o Elements Hospital Plus** o Lumenos HSA 2500 (80/50)** o Classic $40 HMO* o PPO 2400 ( HSA)** o PPO $40 Copay* o Elements Hospital** o Lumenos HSA 3500 (80/50)** o Saver $20 HMO* o PPO 3500 ( HSA)** ** Anthem Blue Cross Life and o PPO $25 Copay GenRx** o Lumenos HIA Plus 750** o High Deductible EPO* o Saver $30 HMO* o Lumenos HIA Plus 3000** Health Insurance Company o PPO $35 Copay GenRx** o Lumenos HIA Plus 500** o Saver $40 HMO* o Power HealthFund 750** o PPO $45 Copay GenRx** Anthem Blue Cross Life and Health o Select $25 HMO* o Power HealthFund 500** o _____________ o Select $35 HMO* 2010 1b. o Dental Blue Silver 100-80** o High Option PPO** o Dental Net* o ________________________________ o Dental Blue Silver Plus 100-80** o Standard Option PPO** o Dental Blue Gold 100-80** o Basic Option PPO** Dental Net o Dental Blue Gold Plus 100-80** o D