Page 7 - PetVet 2022 Master Benefits Guide CA_FINAL Version

Medical - California

PetVet Care Centers offers California residents the following HMO option through
Anthem BlueCross BlueShield of California. Prescription drug coverage is
automatically included as part of your medical plan—no separate election is needed.

The prescription drug benefits access Anthem BCBS’s Essential Drug Formulary.

Anthem Blue Cross Blue Shield Premier HMO 20 / 100%
In-Network
Calendar Year Deductible (1/1 – 12/31)
Single $0
Family $0
Coinsurance 100%
Calendar Year Out-of-Pocket Maximum
Single $1,500
Family $3,000
Out-of-Pocket Maximum Type Embedded
Services
Preventive Care No Charge
Office Visit: Primary Care $20 per visit
Office Visit: Specialist $20 per visit
Lab and X-Ray Services No Charge
Outpatient Hospital and Advanced Diagnostic Imaging (MRI/PET/CAT) $100 per test
Hospital Stay No Charge
Emergency Room $100 per visit
Urgent Care $20 per visit
Retail Rx (30 day supply)
Tier 1a: $5 copay
Tier 1 (generic)
Tier 1b: $15 copay
Tier 2 (brand-preferred) $25 copay
Tier 3 (brand non-preferred) $45 copay
Mail(90 day supply)
Tier 1a: $12.50 copay
Tier 1 (generic)
Tier 1b: $37.50 copay
Tier 2 (brand-preferred) $75 Copay
Tier 3 (brand non-preferred) $135 Copay

If you enroll in the Premier HMO, the plan requires a selection of a Primary Care Physician.
Your plan also requires a referral from your Primary Care Physician for select covered services.

 All benefits information outlined are subject to plan provisions and contract details. The
highlighted benefits are only a brief summary. Please refer to the Summary Plan Description (SPD)
for full details.
 Deductibles, Out-of-Pocket Maximums and frequencies will run on a calendar year basis (1/1 –
12/31)

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