Page 14 - Realty One Benefits Guide CA

EMPLOYEE CONTRIBUTION $$ $$$$ $ $$$ $$$$$

OUT-OF-POCKET COSTS $ $ $$$$ $$$ $$
ANTHEM BLUE CROSS ANTHEM BLUE CROSS ANTHEM BLUE CROSS ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME
HMO 30/40 500 ADMIT CLASSIC HMO 30/40 500 ADMIT LUMENOS HSA PPO 501 SOLUTION PPO 1500 CLASSIC PPO 750 30/20
Blue Cross PPO Blue Cross PPO Blue Cross PPO
NETWORK NAME Select HMO Blue Cross HMO (CACare) - Large Group Non-Network Non-Network Non-Network
(Prudent Buyer) (Prudent Buyer) (Prudent Buyer)
NETWORK SIZE A AA AAAA N/A AAAA N/A AAAA N/A
MEDICAL BENEFITS

Calendar Year Deductible
• Individual $0 $0 $3,000 $6,000 $1,500 $3,000 $750 $1,500
• Family $0 $0 $6,000 $12,000 $3,000 $6,000 $2,250 $4,500
Coinsurance (Plan Pays) 100% 100% 80% 60% 90% 70% 80% 60%
Physician Office Visit
• PCP / Specialist $30 Copay / $40 Copay $30 Copay / $40 Copay Ded, 80% Ded, 60% $20 Copay Ded, 70% $30 Copay Ded, 60%
Out-of-Pocket Maximum
• Individual $2,500 $2,500 $5,000 $12,000 $3,500 $7,000 $5,000 $10,000
• Family $5,000 $5,000 $10,000 $24,000 $7,000 $14,000 $10,000 $20,000
Hospitalization
• Inpatient $500/Admit $500/Admit Ded, 80% Ded, 60% Ded, 90% Ded, 70% Ded, 80% Ded, 60%
• Outpatient Surgery $250/Visit $250/Visit Ded, 80% Ded, 60% Ded, 90% Ded, 70% Ded, 80% Ded, 60%
Emergency Services $100 Copay $100 Copay Ded, 80% Ded, $150 Copay, 90% Ded, $150 Copay, 80%

Urgent Care $30 Copay $30 Copay Ded, 80% Ded, 60% $20 Copay Ded, 70% $30 Copay Ded, 60%
Preventive Care 100% 100% 100% Ded, 60% 100% Ded, 70% 100% Ded, 60%
PHARMACY BENEFITS
Retail Pharmacy - 30 Day Supply
• Tier 1 (Typically Generic) $10 Copay $10 Copay Ded, $10 Copay Ded, Network + 40% $10 Copay Network + 50% $15 Copay Network + 50%
• Tier 2 (Typically Preferred / Brand) $30 Copay $30 Copay Ded, $40 Copay Ded, Network + 40% $30 Copay Network + 50% $30 Copay Network + 50%
• Tier 3 (Typically Non-Preferred / Specialty Drugs) $50 Copay $50 Copay Ded, $60 Copay Ded, Network + 40% $50 Copay Network + 50% $50 Copay Network + 50%
• Tier 4 (Typically Specialty Drugs) 30% Max $250 30% Max $250 Ded, 30% Max $250 Ded, Network + 40% 30% Max $250 Network + 50% 30% Max $250 Network + 50%
Mail Order Pharmacy - 90 Day Supply
• Tier 1 (Typically Generic) $25 Copay $25 Copay Ded, $25 Copay Not Covered $25 Copay Not Covered $37.50 Copay Not Covered
• Tier 2 (Typically Preferred / Brand) $90 Copay $90 Copay Ded, $120 Copay Not Covered $90 Copay Not Covered $90 Copay Not Covered
• Tier 3 (Typically Non-Preferred / Specialty Drugs) $150 Copay $150 Copay Ded, $180 Copay Not Covered $150 Copay Not Covered $150 Copay Not Covered
• Tier 4 (Typically Specialty Drugs) 30% Max $250 30% Max $250 Ded, 30% Max $250 Not Covered 30% Max $250 Not Covered 30% Max $250 Not Covered
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