Page 7 - Bar Bakers EE Guide 09-17 English Final

BENEFITS

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name Low HMO Value High HMO Value Classic PPO
Network Name Priority Select California Care HMO Prudent Buyer PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Calendar Year)
- Individual $0 $0 $1,000 $3,000
- Family $0 $0 $3,000 $9,000

Co-Insurance (Plan Pays) 80% 100% 80% 60%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay $35 Copay Deductible, 40%
- Specialist Office Visit $30 Copay $40 Copay $35 Copay Deductible, 40%
Out-of-Pocket Maximum
- Individual $3,500 $2,500 $5,000 $15,000
- Family $7,000 $5,000 $10,000 $30,000
Hospitalization
- Inpatient 20% $250/Day Deductible, 20% Deductible, 40%*
Max 3 Copays/Adm
- Outpatient 20% $125 Copay Deductible, 20% Deductible, 40%*
Lab and X-Ray
- Diagnostic No Charge - 20% No Charge Deductible, 20% Deductible, 40%
- Advanced $100 Copay - 20% $100 Copay Deductible, 20% Deductible, 40%

Emergency Services $200 Copay $150 Copay $150 Copay, 20%
Urgent Care $20 Copay $20 Copay $35 Copay Deductible, 40%
Preventive Care No Charge No Charge No Charge Deductible, 40%

Chiropractic $20 Copay $20 Copay $35 Copay Deductible, 40%
Limited to 60 Days Limited to 60 Days 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible None None None None

Retail Pharmacy
- Tier 1a/1b $5/$20 copay $5/$20 copay $5/$20 copay $5/$20 copay + 50%
- Tier 2 $40 Copay $30 Copay $30 Copay $30 copay + 50%
- Tier 3 $60 Copay $50 Copay $50 Copay $50 copay + 50%
- Tier 4 30% Max $250 30% Max $250 30% Max $250 50%
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $12.50/$50 Copay $12.50/$50 Copay $12.50/$50 Copay Not Covered
- Tier 2 $120 Copay $90 Copay $90 Copay Not Covered
- Tier 3 $180 Copay $150 Copay $150 Copay Not Covered
- Tier 4 30% Max $250 30% Max $250 30% Max $250 Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

*Limitations apply. See SBC for details.
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