Page 7 - Benefits Guide TeleSign 2020

Medical Coverage Comparison

Anthem Blue Cross Medical Plans

Anthem Anthem Anthem
HMO (CA Only) Traditional PPO HDHP (High Deductible Health Plan)
Network Name Blue Cross HMO Blue Cross PPO Non-Network Blue Cross PPO Non-Network
(CACare) - Large (Prudent Buyer) - (Prudent Buyer) -
Group Large Group Large Group

Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $0 $250 $750 $1,500 $4,500
- Family $0 $750 $2,250 $3,000 $9,000
($2,800/member) ($4,500/ member)
Co-Insurance (Plan Pays) 100% 80% after Ded 60% after Ded 80% after Ded 60% after Ded

Office Visit Copay You Pay: You Pay: You Pay: You Pay: You Pay:
- Primary Care Physician $20 Copay $20 Copay Ded, then 40% Ded, then 20% Ded, then 40%
- Specialist Office Visit $40 Copay $40 Copay Ded, then 40% Ded, then 20% Ded, then 40%
- Urgent Care $20 copay $20 copay Ded, then 40% Ded, then 20% Ded, then 40%
- Preventive Care No charge No charge Ded, then 40% No charge Ded, then 40%
Out-of-Pocket Maximum
- Individual $2,000 $2,500 $7,500 $3,000 $9,000
- Family $4,000 $5,000 $15,000 $6,000 (3k/mem) $18,000 (9k/mem)

Hospitalization
- Inpatient $250 Copay Ded, then 20% Ded, then 40% Ded, then 20% Ded, then 40%
- Outpatient $125 Copay Ded, then 20% Ded, then 40% Ded, then 20% Ded, then 40%
Emergency Services $100 Copay $150 Copay and then 20% Ded, then 20%
Lab and X-Ray
- Diagnostic No charge Ded, then 20% Ded, then 40% Ded, then 20% Ded, then 40%
- Advanced Imaging $100/test Ded, then 20% Ded, then 40% Ded, then 20% Ded, then 40%
Chiropractic $20 Copay $20 Copay Ded, then 40% Ded, then 20% Ded, then 40%
60 visits/year 30 visit limit per year 30 visits/year

Pharmacy Benefits

Pharmacy Deductible n/a n/a n/a Plan deductible Plan deductible
Retail Rx (30 day)
- Tier 1a/Tier 1b $5/$15 $5/$15 $5/$15
- Tier 2 $30 $30 Retail copay + $40 Retail copay +
- Tier 3 $50 $50 50% $60 50%
- Tier 4 30% to $250 max 30% to $250 max 30% to $250 max
Mail Order Rx (90 day)
- Tier 1 $12.50/$37.50 $12.50/$37.50 Not Covered $12.50/$37.50 Not Covered
- Tier 2 $90 $90 Not Covered $120 Not Covered
- Tier 3 $150 $150 Not Covered $180 Not Covered
- Tier 4 (30 day supply) 30% to $250 max 30% to $250 max N/A 30% to $250 N/A

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