Page 6 - KNCH Benefits Guide 2019.pub

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross
Plan Features HMO—CA ONLY EPO (Exclusive PPO)
(AZ, FL, NV, TX ONLY)
Network CACARE‐Large Group Na onal PPO (Blue Card PPO)

HEALTH BENEFITS
Life me Maximum Unlimited Unlimited

Calendar Year Deduc ble
Individual $0 $0
Family $0 $0
Coinsurance (Plan Pays) 100% 100%
Physician Office Visit
PCP $30 Copay $20 Copay
Specialist $40 Copay $20 Copay
Calendar Year Out‐of‐Pocket Maximum
Individual $2,500 $2,500
Family $5,000 $5,000
Hospitaliza on
Inpa ent $500 Copay $250 Copay
Outpa ent $250 Copay $125 Copay
Emergency Services $100 Copay $100 Copay
Urgent Care $30 Copay $20 Copay

Lab and X‐Ray: Basic No Charge No Charge
Complex $100 Copay $100 Copay

Preven ve Care 100% 100%
Chiroprac c $10 Copay $20 Copay
30 Visits/Year 30 Visits/Year
PHARMACY BENEFITS

Retail (30 Day Supply)
Tier 1a / 1b $5 / $15 Copay $5 / $15 Copay
Tier 2 $30 Copay $30 Copay
Tier 3 $50 Copay $50 Copay
Tier 4 $30% up to $250 Copay $30% up to $250 Copay
Mail Order (90 Day Supply)
Tier 1a / 1b $12.50 / $37.50 Copay $12.50 / $37.50 Copay
Tier 2 $90 Copay $90 Copay
Tier 3 $150 Copay $150 Copay
Tier 4 n/a n/a

FINDING A MEDICAL PROVIDER:
Go to www.anthem.com/ca. Note: if you are outside CA, you will then select the state you reside.

 For HMO: Search “Blue Cross HMO (CACARE) ‐ Large Group” or call (800) 888‐8288
 For EXCLUSIVE PPO: Search “Na onal PPO (Blue Card PPO)” or call (800) 888‐8288

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