Page 6 - California Eye Management EE Guide 2019

Medical Benefits

Anthem Blue Cross Anthem Blue Cross
Plan Name Base HMO Deductible HMO
Network Priority Select Network Select Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual) None $500 / member

Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay
- Online Visit Not covered Not covered
Out-of-Pocket Maximum
- Individual $3,000 $3,000
- Family $6,000 $6,000
Hospitalization
- Inpatient $250 per day (3 days max per admission) Deductible, 20%
- Outpatient 20% Deductible, 20%
Lab and X-Ray No charge No charge

Emergency Services $150 Copay $150 Copay, then Deductible, 20%
Urgent Care $20 Copay $20 Copay
Preventive Care No Charge No Charge

Chiropractic / Acupuncture $20 Copay $20 Copay
Coverage for In-Network provider is limited to Coverage for In-Network provider is limited
60 day limit per benefit period for Physical, to 60 day limit per benefit period for
Occupational and Speech Therapy combined. Physical, Occupational and Speech Therapy
Chiropractic visits count towards your combined. Chiropractic visits count
physical and occupational therapy limit. towards your physical and occupational
therapy limit.
Pharmacy Benefits

Pharmacy Deductible None None

Retail Pharmacy
- Tier 1A / Tier 1B $5 / $20 Copay $5 / $20 Copay
- Tier 2 $40 Copay $40 Copay
- Tier 3 $60 Copay $75 Copay
- Tier 4 30% up to $250 30% up to $250
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1A / Tier 1B $12.50 / $50 Copay $12.50 / $50 Copay
- Tier 2 $120 Copay $120 Copay
- Tier 3 $180 Copay $225 Copay
- Tier 4 30% up to $250 30% up to $250
- Supply Limit 90 Days 90 Days

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