Page 12 - HM Benefits Guide 2019 CA

Medical Plans

Anthem Blue Cross Anthem Blue Cross
HMO PPO (Low)
Network Name HMO (CA Care) PPO (Prudent Buyer) Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $0 $750 $2,250
• Family $0 $2,250 $6,750
Out-of-Pocket Maximum
• Individual $2,000 $5,000 $15,000
• Family $4,000 $10,000 $30,000
Coinsurance (You Pay) 0% 20% 40%
Physician Office Visit
• Preventive Care No Charge No Charge Deductible, 40%
• PCP $20 Copay $30 Copay Deductible, 40%
• Specialist $40 Copay $50 Copay Deductible, 40%
• Urgent Care $20 Copay $30 Copay Deductible, 40%
• Telemedicine $10 Copay $10 Copay N/A
Hospitalization
• Inpatient $250 Copay Deductible, 20% Deductible, 40%*
• Outpatient Surgery $125 Copay Deductible, 20% Deductible, 40%*
Emergency Services $100 Copay, 20% $150 Copay, 20%
Chiropractic $20 Copay $30 Copay Deductible, 40%
Limit 60-Day Period 30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
• Tier 1a / 1b $5 / $15 Copay $5 / $20 Copay 40% Max $250
• Tier 2 $30 Copay $30 Copay 40% Max $250
• Tier 3 $50 Copay $50 Copay 40% Max $250
• Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
• Tier 1a / 1b $12 / $37 Copay $12.50 / $50 Copay Not Covered
50
• Tier 2 $90 Copay $90 Copay Not Covered
• Tier 3 $150 Copay $150 Copay Not Covered
• Supply Limit 90 Days 90 Days N/A
Specialty
• Tier 4 30% Max $250 30% Max $250 40% Max $250
• Supply Limit 30 Days (Retail / M.O.) 30 Days (Retail / 30 Days (Retail Only)
M.O.)
*Limitations apply. See SBC for details.

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