Page 11 - Incipio EE Guide 01-19 CA Bi-Weekly

BENEFITS

Medical Insurance

ANTHEM ANTHEM
PLAN NAME PPO 2500 DEDUCTIBLE PPO 500 DEDUCTIBLE
NETWORK NAME Prudent Buyer PPO Non-Network* Prudent Buyer PPO Non-Network*
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $2,500 $7,500 $500 $1,500
- Family $5,000 $15,000 $1,500 $4,500
Co-Insurance (You Pay) 30% 50% 10% 30%
Office Visit Copay
- Primary Care Physician $30 Copay Deductible, 50% $20 Copay Deductible, 30%
- Specialist Office Visit $30 Copay Deductible, 50% $20 Copay Deductible, 30%
- Virtual Visit $10 Copay Deductible, 50% $10 Copay Deductible, 30%
Out-of-Pocket Maximum
- Individual $6,000 $18,000 $3,500 $10,500
- Family $12,000 $36,000 $7,000 $21,000
Hospitalization
- Inpatient Deductible, 30% Deductible, 50% Deductible, 10% Deductible, 30%
- Outpatient Surgery Deductible, 30% Deductible, 50% Deductible, 10% Deductible, 30%

Lab and X-Ray
- Diagnostic $30 Copay Deductible, 50% Deductible, 10% Deductible, 30%
- Advanced $200 Copay Deductible, 50% Deductible, 10% Deductible, 30%
Emergency Services Deductible, $150 Copay, 30% Deductible, $150 Copay, 10%
Urgent Care $30 Copay Deductible, 50% $20 Copay Deductible, 30%
Preventive Care No Charge Deductible, 50% No Charge Deductible, 30%

Chiropractic $30 Copay Deductible, 50% $20 Copay Deductible, 30%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Tier 2, 3, & 4 Deductible None None None None
Retail Pharmacy
- Tier 1a/1b $5/$15 Copay 50% up to $250 $5/$15 Copay 50% up to $250
- Tier 2 $50 Copay 50% up to $250 $30 Copay 50% up to $250
- Tier 3 $65 Copay 50% up to $250 $50 Copay 50% up to $250
- Tier 4 30% Max $250 Copay 50% up to $250 30% Max $250 Copay 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
50
50
50
- Tier 1a/1b $12 /$37 Copay Not Covered $12 /$37 Copay Not Covered
- Tier 2 $150 Copay Not Covered $90 Copay Not Covered
- Tier 3 $195 Copay Not Covered $150 Copay Not Covered
- Tier 4 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
*Limitations apply. See SBC for details.
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