Page 11 - Optima Tax EE Guide 01-20 CA w Kaiser
P. 11

Medical Plan Highlights








                                                   Anthem
                                             Standard  Network                          Anthem
         Plan Name                                Only EPO                            Premier PPO
         Network Name                          Prudent Buyer             Prudent Buyer           Non-Network*
         Plan Differences
         Employee Premiums                            $$                                  $$$$

         Employee Cost Sharing                Contribution, Copay                Contribution, Deductible,
                                                                                    Copay, Coinsurance
         Network
          - Network Size                                                               
          - In-Network Benefits                       ✓                                     ✓
          - Non-Network Benefits                                                            ✓
         Access to Providers                   Managed by You                        Managed by You
         Health Benefits
         Lifetime Max Benefit                      Unlimited                            Unlimited

         Deductible (Cal Year)
          - Individual                                $0                                  $250
          - Family                                    $0                                  $500
         Out-of-Pocket Maximum
          - Individual                              $5,000                    $3,750                $10,250**
          - Family                                  $10,000                   $7,500                $20,500**
         Coinsurance (Plan Pays)                     100%                      80%                    60%*
         Office Visit Copay
          - Preventive Care                       No Charge                 No Charge              Not Covered
          - PCP                                   $30 Copay                 $20 Copay            Deductible, 40%
          - Specialist                            $40 Copay                 $20 Copay            Deductible, 40%
          - Urgent Care                           $30 Copay                 $20 Copay            Deductible, 40%
          - Retail Clinic                         $15 Copay                 $15 Copay            Deductible, 40%
          - Virtual Visits: LiveHealth Online      $5 Copay                  $5 Copay                  N/A
         24/7 Nurseline                           No Charge                 No Charge                  N/A
         Hospitalization
          - Inpatient                             $500/Admit              Deductible, 20%       Deductible, 40%***
          - Outpatient Surgery                    $200 Copay              Deductible, 20%       Deductible, 40%***
         Lab and X-Ray
          - Diagnostic                         $30 - $100 Copay           Deductible, 20%       Deductible, 40%***
          - Radiological/Nuclear               $30 - $200 Copay           Deductible, 20%       Deductible, 40%***
         Emergency Room Services                  $150 Copay                         $150 Copay, 20%

         Chiropractic                             $40 Copay                  $20Copay            Deductible, 40%
         Max 20 Visits/Year
         Acupuncture                              $40 Copay                 $20 Copay            Deductible, 40%
         Max 20 Visits/Year
         *Out of network providers are reimbursed by our plan at Anthem Fee Schedule .

         **The out-of-pocket max, is the most you may pay in a year for covered services. Premiums, balance-billing charges,
         health care this plan doesn’t cover & penalties for failure to obtain pre-authorization for services is NOT included in the
         out-of-pocket limit.

         *** Additional coverage maximums apply to Non-Network providers. Please refer to plan documents for more details.
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