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MEDICAL INSURANCE

CA ONLY NATIONAL NON-CA ONLY
ANTHEM ANTHEM ANTHEM
HMO PPO BCE PPO
Network In-Network In-Network Non-Network In-Network Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible
Individual None $250 None $3,000
Family None $750 None $9,000
Coinsurance (Plan Pays) 100% 80% 60% 100% 50%
Physician Office Visit
PCP $20 Copay $20 Copay Ded, 60% $20 Copay Ded, 50%
Specialist $40 Copay $20 Copay Ded, 60% $20 Copay Ded, 50%
Out-of-Pocket Maximum
Individual $2,000 $3,500 $10,500 $2,500 $9,000
Family $4,000 $7,000 $21,000 $5,000 $18,000
Hospitalization
Inpatient $250 Copay Ded, 80% Ded, 60% $250 Copay Ded, 50%
Outpatient Surgery $125 Copay Ded, 80% Ded, 60% $125 Copay Ded, 50%
Emergency Services $100 Copay $100 Copay, 80% $100 Copay
Urgent Care $20 Copay $20 Copay Ded, 60% $20 Copay Ded, 50%
Lab & X-ray 100%, $100 Ded, 80% Ded, 60% 100%, $100 Ded, 50%
Complex Complex
LiveHealth Online $49 Copay $10 Copay $10 Copay
Preventive Care 100% 100% Ded, 60% 100% Ded, 50%
Acupuncture $10 Copay $20 Copay Ded., 60% $20 Copay Ded., 50%
20 Visits/Year 20 Visits/Year
Chiropractic $20 Copay $20 Copay Ded, 60% $20 Copay Ded, 50%
30 Visits/Year 30 Visits/Year 30 Visits/Year
PHARMACY BENEFITS
Annual Deductible None None None None None
Retail Pharmacy
Tier 1a $5 Copay $5 Copay $5 Copay
Tier 1b $15 Copay $15 Copay 50% of $15 Copay 50% of
Tier 2 $30 Copay $25 Copay Coinsurance $30 Copay Coinsurance
Tier 3 $50 Copay $45 Copay $50 Copay
Tier 4 30% Max $250 30% Max $250 30% Max $250
Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
Tier 1a $12.50 Copay $12.50 Copay Not Covered $12.50 Copay Not Covered
Tier 1b $37.50 Copay $37.50 Copay Not Covered $37.50 Copay Not Covered
Tier 2 $90 Copay $75 Copay Not Covered $90 Copay Not Covered
Tier 3 $150 Copay $135 Copay Not Covered $150 Copay Not Covered
Tier 4 30% Max $250 30% Max $250 Not Covered 30% Max $250 Not Covered
Supply Limit 90 Days 90 Days N/A 90 Days N/A

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