Page 3 - Flyer Employee Benefits Brochure FINAL 2021 CA w_compliance notices update 3_10
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Flyer Defense
2021–22 Employee Benefits Brochure
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Medical Plans
Anthem Blue Cross Classic HMO (CA Care)
In- Network only
Deductible:
Individual $0
Family $0
Out-of-Pocket Limit (per calendar year)
Individual $2,000
Family $4,000
Hospital Services:
Inpatient $500 copay per admission
Outpatient Surgery $125 copay per admission
Emergency Room (waived if admitted) $250 copay per visit
Physician Services:
Office Visit (PCP/Specialist) $20 / $40 copay per visit
Pre-Natal Maternity $20 copay per visit
Diagnostic Lab & X-Ray No charge
Imaging (CT/PET scans, MRIs) $100 copay per test
Urgent Care $20 copay per visit
Acupuncture $20 copay up to 20 visits
Chiropractor $20 copay up to 20 visits
Physical Therapy $20 copay up to 40 visits
Routine Care:
Preventative Checkups No charge
Prescription Drugs:
Generic Drugs - Tier 1 $10 retail/$25 Mail order
Preferred Brand- Tier 2 $20 retail/$60 Mail order
Non-Preferred Brand- Tier 3 $35 retail/$105 Mail order
Specialty Drugs- Tier 4 20% up to $250 per RX
DME (Durable Medical Equipment) 20% coinsurance
Retail Rx: Up to a 30 day supply from retail pharmacy
Mail Oder Rx: 31-90 day supply from Anthem RX Home Delivery
For Non-Network Provider benefits refer to the Benefit Summary.
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