Page 6 - Tongle Benefits Guide 2018 - CA Final

BENEFITS

Medical Insurance

Anthem Anthem Anthem
Plan Name Gold HMO Gold PPO Platinum PPO
25 / 20% / 5500 1,000 / 20% / 6000 200 / 10% / 3000

Network Name CACare Prudent Buyer Non-Network* Prudent Buyer Non-Network*
Health Benefits

Lifetime Max Benefit Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual None $1,000 $2,000 $200 $400
- Family None $3,000 $4,000 $600 $800
Co-Insurance (You Pay) N/A 20% 50% 10% 50%
Office Visit Copay
- Primary Care Physician $25 Copay $20 Copay Deductible, 50% $10 Copay Deductible, 50%
- Specialist Office Visit $50 Copay $40 Copay Deductible, 50% $30 Copay Deductible, 50%

Out-of-Pocket Maximum
- Individual $5,500 $6,000 $12,000 $3,000 $6,000
- Family $11,000 $12,000 $24,000 $6,000 $12,000
Hospitalization
- Inpatient $500/Day, Max 3 Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
- Outpatient $250 Copay Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
Lab and X-Ray
- Diagnostic $25 Copay Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
- Advanced Imaging $250 Copay $100 Copay, Deductible, 50% $100 Copay, Deductible, 50%
Deductible, 20% Deductible, 10%
Emergency Services $250 Copay $250 Copay, Deductible, 20% $200 Copay, Deductible, 10%
Urgent Care $50 Copay $40 Copay Deductible, 50% $20 Copay Deductible, 50%

Preventive Care No Charge No Charge Deductible, 50% No Charge Deductible, 50%
Chiropractic $25 Copay Deductible, 50% Not Covered Deductible, 50% Not Covered
Max 20 Visits/Year Max 20 Visits/ Max 20 Visits/
Year Year
Pharmacy Benefits
Retail Pharmacy
- Tier 1a $5 Copay $5 Copay $5 Copay
- Tier 1b $15 Copay $20 Copay Not $15 Copay Not
- Tier 2 $35 Copay $40 Copay Covered $35 Copay Covered
- Tier 3 $70 Copay $80 Copay $70 Copay
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a $13 Copay $13 Copay $13 Copay
- Tier 1b $38 Copay $50 Copay Not $38 Copay Not
- Tier 2 $105 Copay $120 Copay Covered $105 Copay Covered
- Tier 3 $210 Copay $240 Copay $210 Copay
- Supply Limit 90 Days 90 Days 90 Days
*Non-Network benefits are based off of the plan’s non-network reimbursement schedule, and various benefits have limitations.

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