Page 7 - KNCH Benefits Guide 2019.pub

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross
Plan Features HSA Solution PPO

Network CA: PPO Non‐Network CA: PPO Non‐Network
Non‐CA: Na onal PPO Non‐CA: Na onal PPO
HEALTH BENEFITS

Life me Maximum Unlimited Unlimited
Calendar Year Deduc ble
Individual $1,500 $4,500 $1,500 $4,500

Individual in a Family $2,700 $4,500 $1,500 $4,500
Family $3,000 $9,000 $3,000 $9,000
Coinsurance (Plan Pays) 90% 70% 80% 60%
Physician Office Visit
PCP Deduc ble, 90% Deduc ble, 70% $15 Copay Deduc ble, 60%
Specialist Deduc ble, 90% Deduc ble, 70% $15 Copay Deduc ble, 60%
Calendar Year Out‐of‐
Pocket Maximum
Individual $3,000 $9,000 $3,500 $10,500
Individual in a Family $3,000 $9,000 $3,500 $10,500
Family $6,000 $18,000 $7,000 $21,000
Hospitaliza on
Inpa ent Deduc ble, 90% Deduc ble, 70% Deduc ble, 80% Deduc ble, 60%
Outpa ent Deduc ble, 90% Deduc ble, 70% Deduc ble, 80% Deduc ble, 60%

Emergency Services Deduc ble, 90% Deduc ble, $150 copay, 80%
Urgent Care Deduc ble, 90% Deduc ble, 70% $15 Copay Deduc ble, 60%
Lab and X‐Ray: Deduc ble, 90% Deduc ble, 70% Deduc ble, 80% Deduc ble, 60%
Preven ve Care 100% Deduc ble, 70% 100% Deduc ble, 60%

Chiroprac c Deduc ble, 90% Deduc ble, 70% $15 Copay Deduc ble, 60%
30 Visits/Year 30 Visits/Year

PHARMACY BENEFITS Full plan deduc ble must be met prior to
prescrip on copays
Retail (30 Day Supply)
Tier 1a / 1b $5 / $15 Copay $5 / $20 Copay
Tier 2 $40 Copay 50% up to $250 $40 Copay 50% up to $250
Tier 3 $60 Copay Copay per Script $60 Copay Copay per Script
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 / $50 Copay
Tier 2 $120 Copay Not Covered $120 Copay Not Covered
Tier 3 $180 Copay $180 Copay
Tier 4 n/a n/a

FINDING A MEDICAL PROVIDER:

Go to anthem.com/ca. Note: if you are outside CA, you will then select the state you reside:
 (CA Employees) For PPO & HSA: Select “Blue Cross PPO (Prudent Buyer) ‐ Large Group” or call (800) 888‐8288
 (NON‐CA Employees) For PPO & HSA: Select “Na onal PPO (Blue Card PPO)” or call (866) 207‐9878
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