Page 10 - Optima Tax EE Guide 01-20 CA

Medical Plan Highlights

Anthem
Plan Name Basic PPO
Network Name Prudent Buyer Non-Network*

Plan Differences
Employee Premiums $
Employee Cost Sharing Contribution, Deductible,
Copay, Coinsurance
Network
- Network Size 
- In-Network Benefits ✓
- Non-Network Benefits ✓
Access to Providers Managed by You

Health Benefits
Lifetime Max Benefit Unlimited
Deductible (Cal Year)
- Individual $1,500
- Family $3,000
Out-of-Pocket Maximum
- Individual $6,000 $12,000**
- Family $12,000 $24,000**
Coinsurance (Plan Pays) 80% 50% *
Office Visit Copay
- Preventive Care No Charge Not Covered
- PCP $30 Copay Deductible, 50%
- Specialist $40 Copay Deductible, 50%
- Urgent Care $30 Copay Deductible, 50%
- Retail Clinic $15 Copay Deductible, 50%
- Virtual Visits: LiveHealth Online $5 Copay N/A
24/7 Nurseline No Charge N/A

Hospitalization
- Inpatient Deductible, 20% Deductible, 50%***
- Outpatient Surgery Deductible, 20% Deductible, 50%***
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 50%***
- Radiological/Nuclear Deductible, 20% Deductible, 50%***
Emergency Room Services 20%
Chiropractic $40 Copay Deductible, 50%
Max 20 Visits/Year
Acupuncture $40 Copay Deductible, 50%
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.

10 Employee Benefits