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Benefits

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Value HMO (CA EE’s ONLY) Network PPO2

Network Name Select Network In Network Only
Health Benefits
Deductible (Calendar Year)
- Individual $0 $3,000
- Family $0 $6,000
Co-Insurance (Plan Pays) 100% 70%
Office Visit Copay
- Primary Care Physician $20 Copay $25 Copay
- Specialist Office Visit $40 Copay $60 Copay
- On-Line Visits $10 Copay $10 Copay
Out-of-Pocket Maximum (Calendar Yr)
- Individual $2,500 $5,000
- Family $5,000 $10,000
Hospitalization
- Inpatient $250 copay per day Deductible, 30%
(3 days copay max per admit)
- Outpatient $125 copay per admit Deductible, 30%
Lab and X-Ray (non-complex) No Charge 30%
Lab and X-Ray (complex) $100 copay per test Deductible, 30%

Emergency Services $150 Copay $250 Copay + 30%
Urgent Care $20 Copay $25 Copay
Preventive Care No Charge No Charge
Chiropractic/Acupuncture $20 Copay $25 Copay
Pharmacy Benefits

Pharmacy Deductible *
- Individual (Except Tier 1) $0 $250
Retail Pharmacy
- Tier 1 Generic Formulary $5-$15 Copay $15 Copay
- Tier 2 Brand Name Formulary $30 Copay Ded, $35 Copay *
- Tier 3 Non-Formulary $50 Copay Ded, $75 Copay*
- Tier 4 Specialty Rx 30% up to $250 per script 30% up to $350 per script
Retail Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 Generic Formulary $12.50-$37.50 Copay $45 Copay
- Tier 2 Brand Name Formulary $90 Copay Ded, $105 Copay *
- Tier 3 Non-Formulary $150 Copay Ded, $225 Copay *
- Tier 4 Specialty Rx 30% up to $250 per script 30% up to $700 per script
Mail Order Supply Limit 90 Days 90 Days

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