Page 11 - SunWest EE Guide 09-19 CA

Medical Plan highlights

Anthem Blue Cross Anthem Blue Cross
Plan Name HSA PPO PPO

Prudent Non- Prudent Non-
Network Name Buyer PPO Network* Buyer PPO Network*
Plan Differences

Employee Premiums $$$ $$$$
Health Savings Account  
- Employee Funded 
Employee Cost Sharing Contribution, Deductible, Contribution, Deductible, Copay,
Coinsurance Coinsurance
Network  
- Network Size  
- In-Network Benefits  
- Non-Network Benefits  

Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Max Benefit Unlimited Unlimited
Deductible (Cal Year)
- Individual $2,000 $6,000 $2,500 $2,500
- Per Member $2,700 $6,000 $2,500 $2,500
- Family $4,000 $12,000 $5,000 $5,000
Out-of-Pocket Maximum
- Individual $3,000 $9,000 $6,350 $10,500
- Per Member $3,000 $9,000 $6,350 $10,500
- Family $6,000 $18,000 $12,700 $21,000

Coinsurance (Plan Pays) 80% 60% 80% 50%
Office Visit Copay
- Preventive Care No Charge Ded, 40% No Charge Ded, 50%
- PCP Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Specialist Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Urgent Care Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Virtual Visits Ded, 20% Ded, 40% $5 Copay Ded, 50%

Hospitalization
- Inpatient Ded, 20% Ded, 40% Ded, $100 Copay, Ded, 50%
20%
- Outpatient Surgery Ded, 20% Ded, 40% Ded, 20% Ded, 50%
Emergency Services Ded, 20% Ded, $100 Copay, 20%

Chiropractic Ded, 20% Ded, 40% $25 Copay Ded, 50%
Max 30 Visits/Year Max 30 Visits/Year

Acupuncture Ded, 20% Ded, 40% $25 Copay Ded, 50%
Max 20 Visits/Year Max 20 Visits/Year
*Limitations apply to non-network benefits. See SBC for details.

Employee Benefits 11