Page 10 - Incipio EE Guide 01-18 CA Semi-Monthly - Final

BENEFITS

Medical Insurance

ANTHEM KAISER
PLAN NAME HMO HMO
NETWORK NAME Full HMO (CA Care) Kaiser Permanente
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual None None
- Family None None
Co-Insurance (You Pay) N/A N/A

Office Visit Copay
- Primary Care Physician $35 Copay $30 Copay
- Specialist Office Visit $50 Copay $50 Copay

Out-of-Pocket Maximum
- Individual $4,500 $3,500
- Family $9,000 $7,000
Hospitalization
- Inpatient $500/Day Copay, 3 Day Max $500/Day Copay
- Outpatient Surgery $250 Copay $250 Copay
Lab and X-Ray
- Diagnostic No Cost $10 Copay
- Advanced $100 Copay $100 Copay

Emergency Services $150 Copay $150 Copay
Urgent Care $35 Copay $30 Copay
Preventive Care No Charge No Charge

Chiropractic $35 Copay $15 Copay
60 Days Limit/Benefit Period 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible None None

Retail Pharmacy
- Tier 1a/1b $5/$15 Copay $15 Copay
- Tier 2 $30 Copay $35 Copay
- Tier 3 $50 Copay N/A
- Tier 4 30% Max $250 Copay N/A
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
50
50
- Tier 1a/1b $12 /$37 Copay $30 Copay
- Tier 2 $150 Copay $70 Copay
- Tier 3 $195 Copay N/A
- Tier 4 30% Max $250 Copay N/A
- Supply Limit 90 Days 100 Days
Please refer to the Summary of Benefits and Coverages (SBCs) provided by Anthem and Kaiser for additional
plan details. These documents are located on ADP.
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