Page 7 - Column Five EE Guide 12-19 -California

BENEFITS

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Silver PPO 55/1750/35% Silver PPO 40/1750/40%
Network Name Prudent Buyer Non-Network Prudent Buyer Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $1,750 $3,500 $1,750 $3,500
- Family $3,500 $7,000 $3,500 $7,000
Out-of-Pocket Maximum
- Individual $7,700 $15,400 $7,600 $15,200
- Family $15,400 $30,800 $15,200 $30,400

Co-Insurance (Plan Pays) 65% 50% 60% 50%
Office Visit Copay
- Preventive Care No Charge Deductible, 50% No Charge Deductible, 50%
- Primary Care Physician $55 Copay Deductible, 50% $40 Copay Deductible, 50%
- Specialist Office Visit $80 Copay Deductible, 50% $70 Copay Deductible, 50%
- Urgent Care $80 Copay Deductible, 50% $70 Copay Deductible, 50%
- Life Health online $20 Copay Not covered $20 Copay Not covered

Hospitalization
- Inpatient Deductible, 35% Deductible, 50%* Deductible, 40% Deductible, 50%
- Outpatient Surgery Deductible, 35% Deductible, 50%* Deductible, 40% Deductible, 50%
Lab and X-Ray
- Diagnostic Deductible, 35% Deductible, 50% Deductible, 40% Deductible, 50%
- Complex Deductible, 35%, $100 Deductible, 50%* Deductible, 40%, $100 Deductible, 50%
Emergency Services Deductible, $300 Copay, 35% Deductible, $250 Copay, 40%

Chiropractic Deductible, 50% Not covered Deductible, 50% Not covered
20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible Waived for generics Waived for generics
- Individual $300 N/A $400 N/A
- Family $600 N/A $800 N/A

Retail (30 Day Supply)
- Generic Formulary $20 Copay Not Covered $20 Copay Not Covered
- Brand Name Formulary $50 Copay Not Covered $50 Copay Not Covered
- Non-Formulary $90 Copay Not Covered $90 Copay Not Covered
- Specialty 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered
Mail Order (90 Day Supply)
- Generic Formulary $50 Copay Not Covered $50 Copay Not Covered
- Brand Name Formulary $150 Copay Not Covered $150 Copay Not Covered
- Non-Formulary $270 Copay Not Covered $270 Copay Not Covered
- Specialty 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered

*Limitations apply. See SBC for details.

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