Page 11 - Incipio EE Guide 01-18 CA Semi-Monthly - Final

BENEFITS

Medical Insurance

ANTHEM ANTHEM
PLAN NAME PPO 2500 DEDUCTIBLE PPO 500 DEDUCTIBLE
NETWORK NAME Prudent Buyer PPO Non-Network Prudent Buyer PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $2,500 $7,500 $500 $1,500
- Family $5,000 $15,000 $1,500 $4,500
Co-Insurance (You Pay) 30% 50% 10% 30%
Office Visit Copay
- Primary Care Physician $30 Copay Deductible, 50% $20 Copay Deductible, 30%
- Specialist Office Visit $30 Copay Deductible, 50% $20 Copay Deductible, 30%

Out-of-Pocket Maximum
- Individual $6,000 $18,000 $3,500 $10,500
- Family $12,000 $36,000 $7,000 $21,000
Hospitalization
- Inpatient Deductible, 30% Deductible, 50%* Deductible, 10% Deductible, 30%*
- Outpatient Surgery Deductible, 30% Deductible, 50%* Deductible, 10% Deductible, 30%*
Lab and X-Ray
- Diagnostic $30 Copay Deductible, 50%* Deductible, 10% Deductible, 30%*
- Advanced $200 Copay Deductible, 50%* Deductible, 10% Deductible, 30%*
Emergency Services Deductible, $150 Copay, 30% Deductible, $150 Copay, 10%

Urgent Care $30 Copay Deductible, 50% $20 Copay Deductible, 30%
Preventive Care No Charge Deductible, 50% No Charge Deductible, 30%
Chiropractic $30 Copay Deductible, 50% $20 Copay Deductible, 30%
30 Visits/Year 30 Visits/Year

Pharmacy Benefits
Tier 2, 3, & 4 Deductible $500/Member $500/Member None None
Retail Pharmacy
- Tier 1a/1b $5/$20 Copay Copay + 50% $5/$15 Copay Copay + 50%
- Tier 2 $50 Copay Copay + 50% $30 Copay Copay + 50%
- Tier 3 $65 Copay Copay + 50% $50 Copay Copay + 50%
- Tier 4 30% Max $250 Copay Copay + 50% 30% Max $250 Copay Copay + 50%
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
50
50
50
- Tier 1a/1b $12 /$37 Copay Not Covered $12 /$37 Copay Not Covered
- Tier 2 $150 Copay Not Covered $150 Copay Not Covered
- Tier 3 $195 Copay Not Covered $195 Copay Not Covered
- Tier 4 30% Max $250 Copay Not Covered 30% Max $250 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
*Limitations apply. See SBC for details.
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