Page 5 - 2017 Employee Benefit Highlights

Medical plan overview | The following chart summarizes some of the features and coverage levels of the medical plan. Refer to the
Summary Plan Description (SPD) for a complete description of covered services and benefits. Please note that plan designs in California vary
slightly from those out of California – please consult the plan documents for exact benefits.
Deductible: The calendar year amount you pay before the plan will pay any Coinsurance: The cost share that you pay for covered services AFTER the
coinsurance benefits. deductible. For example, if the Plan pays 80% after deductible you would be
Out-of-pocket maximum (max.): The maximum amount you will pay for responsible for the remaining 20% of the bill.
covered services in a calendar year. This includes all out-of-pocket expenses Copay: A flat amount paid by the covered individual each time a medical service
including deductibles, copays and coinsurance. is assessed.
Medical HMO Kaiser (CA only) PPO Anthem HDHP 1500 Anthem HDHP 2500 Anthem

Deductible In-Network: In-Network:* In-Network:* *If any dependents
Individual / Family $1,000 / $2,000 $1,000 / $3,000 $1,500 / $3,000 $2,500 / $5,000 are enrolled, you
Out-of-Network: Out-of-Network:* Out-of-Network:* must meet the
$3,000 / $8,000 $1,500 / $3,000 $2,500 / $5,000 family deductible
before the plan
Out-of-pocket max. In-Network:** In-Network:* In-Network: pays (except for
Individual / Family $3,000 / $6,000 $4,000 / $8,000 $3,000 / $6,000 $5000 / $10,000 preventive care
Out-of-Network:** Out-of-Network:* Out-of-Network: services and certain
maintenance
$8,000 / $16,000 $6,000 / $12,000 $10,000 / $20,000 drugs.) Also, if any
Lifetime benefit max. Unlimited Unlimited Unlimited Unlimited dependents are
enrolled, you must
Routine medical $30 copay, no deductible In-Network: In-Network: In-Network: meet the family
office visit $30/visit, no deductible 20% after deductible 20% after deductible out-of-pocket
Office and home visits Out-of-Network: Out-of-Network: Out-of-Network: maximum before
40% after deductible 40% after deductible 40% after deductible the plan pays
100% of the usual,
Specialist $30 copay, no deductible In-Network: In-Network: In-Network: customary and
Office visit $40 copay, no deductible 20% after deductible 20% after deductible reasonable charges
Out-of-Network: Out-of-Network: Out-of-Network: for covered services.
The out-of-pocket
40% after deductible 40% after deductible 40% after deductible maximum includes
Diagnostic X-ray $10 copay, per encounter In-Network: In-Network: In-Network: the deductible.
no deductible 20% after deductible 20% after deductible 20% after deductible ** Includes
Out-of-Network: Out-of-Network: Out-of-Network: deductible, all
40% after deductible 40% after deductible 40% after deductible copays, including
Preventive care $0 copay, no deductible In-Network: In-Network: In-Network: pharmacy, apply to
services $0 copay, no deductible $0 copay, no deductible $0 copay, no deductible the out-of-pocket
maximum.
Out-of-Network: Out-of-Network: Out-of-Network:
40% after deductible 40% after deductible 40% after deductible
Inpatient hospital 20% after deductible In-Network: In-Network: In-Network:
care 20% after deductible 20% after deductible 20% after deductible
Out-of-Network: Out-of-Network: Out-of-Network:
40% after deductible 40% after deductible 40% after deductible
Outpatient surgery 20% after deductible In-Network: In-Network: In-Network:
20% after deductible 20% after deductible 20% after deductible
Out-of-Network: Out-of-Network: Out-of-Network:
40% after deductible 40% after deductible 40% after deductible
Urgent care $30/visit, In-Network: In-Network: In-Network:
deductible waived $50/visit, deductible waived 20% after deductible 20% after deductible
Out-of-Network: Out-of-Network: Out-of-Network:
40% after deductible 40% after deductible 40% after deductible
Emergency room 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Retail Generic: $10 copay, Tier 1 $10 copay In-Network:*** In-Network:*** ***Certain
prescription no deductible Tier 2 $25 copay 20% after deductible 20% after deductible preventive and
(up to a 100-day supply) Tier 3 $50 copay (30-day supply) (30-day supply) maintenance drugs

Brand: $30 after $250 (30-day supply for Tiers 1-3) Out-of-Network: Out-of-Network covered at $0 cost.

deductible for certain drugs Tier 4 20%, $200 max.**** 40% after deductible 40% after deductible
(up to a 100-day supply) (up to 30-day supply) (30-day supply) (30-day supply)
Specialty Drugs: 20%, Retail90: 3 times copay Retail90: 90-day Retail90: 90-day **** Maximum
per prescription.
$150 max., no deductible (90-day supply, maintenance supply, maintenance supply, maintenance Refer to SPD for
(up to 30-day supply)**** drugs only for Tiers 1-3) drugs only for Tiers 1-3 drugs only for Tiers 1-3 details.

Mail order Not applicable Tier 1 $30 copay In-Network:*** In-Network:***
prescription Tier 2 $75 copay 20% after deductible 20% after deductible
Tier 3 $150 copay (90-day supply) (90-day supply)
(90-day supply for Tiers 1-3) Out-of-Network: Out-of-Network:
Tier 4 20%, $200 max.**** Not applicable Not applicable
(up to 30-day supply)
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