Page 7 - California Eye Management EE Guide 2019

Medical Benefits

Anthem Blue Cross Anthem Blue Cross
Plan Name HSA PPO
Network Network Non-Network Network Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual) Health and Pharmacy Deductible Health Deductible Only
- Individual $3,500 $10,500 $1,000 $3,000
- Family $7,000 $21,000 $3,000 $9,000
Co-Insurance (Plan Pays) 80% 50% 80% 60%
Office Visit Copay
- Primary Care Physician Deductible, 20% Deductible, 50% $35 Copay Deductible, 40%
- Specialist Office Visit Deductible, 20% Deductible, 50% $35 Copay Deductible, 40%
- Online Visit Deductible, 20% Deductible, 50% $10 Copay Deductible, 40%
Out-of-Pocket Maximum Includes Annual Deductible Includes Annual Deductible
- Individual $5,500 $16,500 $5,000 $15,000
- Family $11,000 $33,000 $10,000 $30,000
Hospitalization
- Inpatient Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
w/limits w/limits
- Outpatient Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
w/limits w/limits

Lab and X-Ray Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services Deductible, 20% $150 Copay, then Deductible, 20%
Urgent Care Deductible, 20% Deductible, 50% $35 Copay Deductible, 40%
Preventive Care No Charge Deductible, 50% No Charge Deductible, 40%

Chiropractic/Acupuncture Deductible, 20% Deductible, 50% $35 Copay Deductible, 40%
Coverage for In-Network Providers and Non- Coverage for In-Network Providers and Non-
Network Providers combined is limited to 30 visit Network Providers combined is limited to 30
limit per benefit period. visit limit per benefit period.
Pharmacy Benefits

Pharmacy Deductible Health Deductible Applies None
Retail Pharmacy
- Tier 1A / Tier 1B Deductible, $5 / $15 Ded, + 50% up to $250 $5 / $20 Copay 50% up to $250
- Tier 2 Deductible, $40 Copay Ded, + 50% up to $250 $30 Copay 50% up to $250
- Tier 3 Deductible, $60 Copay Ded, + 50% up to $250 $50 Copay 50% up to $250
- Tier 4 30% up to $250 Ded, + 50% up to $250 30% up to $250 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy Deductible,
- Tier 1A / Tier 1B $12.50 / $37.5 Copay Not Covered $12.50 / $50 Copay Not Covered
- Tier 2 Deductible, $120 Copay Not Covered $90 Copay Not Covered
- Tier 3 Deductible, $180 Copay Not Covered $150 Copay Not Covered
- Tier 4 30% up to $250 Not Covered 30% up to $250 Not Covered
- Supply Limit 90 Days 90 Days

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