Page 7 - Career Group Guide 2020 - Temporary CA

Medical Plan Highlights

Anthem Blue Cross Anthem Blue Cross
Plan Name Elements Choice HMO Elements Choice PPO

Blue Cross PPO
Blue Cross HMO (CA (Prudent Buyer) Large
Network Name Care) Large Group Group Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $5,900 per person $6,500 $19,500
- Family $13,000 $39,000
Out-of-Pocket Maximum
- Individual $6,400 $7,350 $22,050
- Family $12,800 $14,700 $44,100

Co-Insurance (Plan Pays) 70% 100% 50%

Office Visit Copay
- Preventive Care No Charge No Charge Deductible, 50%
- Primary Care Physician $35 Copay $35 Copay* Deductible, 50%
- Specialist Office Visit $70 Copay $35 Copay* Deductible, 50%
- Urgent Care $35 Copay Deductible, 0% Deductible, 50%
- Telemedicine $10 Copay $35 Copay* Deductible, 50%
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Hospitalization
- Inpatient Deductible, 30% Deductible, 0% Deductible, 50%
- Outpatient Deductible, 30% Deductible, 0% Deductible, 50%
Lab and X-Ray
- Diagnostic No Charge Deductible, 0% Deductible, 50%
- Complex $100 Copay Deductible, 0% Deductible, 50%
Emergency Services Deductible, $250 Copay, Deductible, 0%
30%

Chiropractic $35 Copay $35 Copay* Deductible, 50%
60 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible $500/$1,500 $500/$1,500 $500/$1,500
Retail Pharmacy
- Generic Formulary $5/$20 Copay $5/$20 Copay 50% to $250
- Brand Name Formulary Deductible, $50 Copay Deductible, $50 Copay Deductible, 50% to $250
- Non-Formulary Deductible, $65 Copay Deductible, $65 Copay Deductible, 50% to $250
- Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $12.50/$50 Copay $12.50/$50 Copay Not Covered
- Brand Name Formulary Deductible, $150 Copay Deductible, $150 Copay Not Covered
- Non-Formulary Deductible, $195 Copay Deductible, $195 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A

*$35 copay per visit for the first 3 visits, then 0% coinsurance after deductible is met.

Employee Benefits 7