Page 7 - Asian Box Guide FINAL 9.11

Medical Plans

Anthem Blue Cross Anthem Blue Cross
Plan Name BASE HMO 1 HMO 2
Silver 55 3KJR Gold 35 306V
Network Name Select Network California Care Network
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0
- Family $0 $0
Out-of-Pocket Maximum
- Individual $7,900 $5,500
- Family $15,800 $11,000
Co-Insurance (Plan Pays) 100% 100%

Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $55 Copay $35 Copay
- Specialist Office Visit $85 Copay $70 Copay
- Urgent Care $55 Copay $35 Copay
- Live Health Online No charge for first 3 visits; No charge for first 3 visits;
after $20 Copay after $15 Copay
Hospitalization
- Inpatient $500 Copay / day up to 4 days $750 Copay / day up to 3 days
- Outpatient $500 Copay $500 Copay
Lab and X-Ray
- Diagnostic $50 Lab /$ 75 X-Ray $25 Lab /$ 40 X-Ray
- Complex $350 Copay $250 Copay

Emergency Services $350 Copay, waived if admitted $250 Copay, waived if admitted
Chiropractic $55 Copay $35 Copay
20 Visits/Year 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $500 $0
- Family $1,000 $0
Retail Pharmacy
- Generic Formulary Tier 1a - $5 Retail/Tier 1b -$20 Retail Tier 1a - $5 Retail /Tier 1b -$20 Retail
- Brand Name Formulary $80 Copay; after deductible $40 Copay; after deductible
- Non-Formulary $110 Copay; after deductible $80 Copay; after deductible
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary Tier 1a - $13 /Tier 1b - $50 Copay Tier 1a - $13/Tier 1b - $50 Copay
- Brand Name Formulary $240 Copay; after deductible $120 Copay
- Non-Formulary $330 Copay; after deductible $240 Copay
- Supply Limit 90 Days 90 Days

Employee Benefits 7