Page 6 - Cylance EE Guide 01-19 All Employees
P. 6
BENEFITS
Medical Insurance
Kaiser Permanente Anthem Blue Cross
Plan Name HMO (CA EEs Only) EPO
Network Name Kaiser Permanente Prudent Buyer PPO
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $0 $100
- Family $0 $200
Co-Insurance (Plan Pays) 100% 90%
Office Visit Copay
- Primary Care Physician $20 Copay $15 Copay
- Specialist Office Visit $35 Copay $30 Copay
Out-of-Pocket Maximum
- Individual $1,500 $3,500
- Family $3,000 $7,000
Hospitalization
- Inpatient $250 Copay Deductible, 10%
- Outpatient $35 Copay Deductible, 10%
Lab and X-Ray
- Diagnostic 100% $15 Copay
- Complex 100% Deductible, 10%
Emergency Services $100 Copay Deductible, $150 Copay, 10%
Urgent Care $20 Copay $15 Copay
Preventive Care No Charge No Charge
Chiropractic $15 Copay $15 Copay
20 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible $0 $0
Retail Pharmacy
- Tier 1 Generic: $10 Copay $10 Copay
- Tier 2 Brand Name: $35 Copay $30 Copay
- Tier 3 N/A $50 Copay
- Tier 4 20% Max $150 Copay 30% Max $350 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 Generic: $20 Copay $25 Copay
- Tier 2 Brand Name: $70 Copay $90 Copay
- Tier 3 N/A $150 Copay
- Tier 4 N/A 30% Max $350 Copay*
- Supply Limit 100 Days 90 Days
*Tier 4 mail order supply limit is 30 days.
6
