Page 5 - 2017 MegaPath Benefits Guide_FINAL

BENEFITS

Health Plan Highlights

All Locations Northern California
Only

Anthem Blue Cross Kaiser Permanente
Plan Name PPO HMO
Network Network Non‐Network Kaiser Facili es Only
Health Benefits
Life me Maximum Benefit Unlimited Unlimited Unlimited

Deduc ble (Annual)
‐ Individual $500 $1,500 $0
‐ Family $1,500 $4,500 $0
Co‐Insurance (Plan Pays) 90% 70% 100%
Office Visit Copay
‐ Primary Care Physician $20 Copay Deduc ble, 30% $25 Copay
‐ Specialist Office Visit $20 Copay Deduc ble, 30% $25 Copay

Out‐of‐Pocket Maximum
‐ Individual $3,500 $10,500 $1,500
‐ Family $7,000 $21,000 $3,000
Hospitaliza on
‐ Inpa ent Deduc ble, 10%* Deduc ble, 30%* $250 Copay

‐ Outpa ent Deduc ble, 10% Deduc ble, 30% $25 Copay
Max $350 Benefit/Year
Lab and X‐Ray Deduc ble, 10% Deduc ble, 30% No Charge

Emergency Services $150 Copay, 10% $150 Copay, 10% $100 Copay
Urgent Care $20 Copay Deduc ble, 30% $25 Copay
Preven ve Care No Charge Deduc ble, 30% No Charge
Chiroprac c $20 Copay Deduc ble, 30% $15 Copay

Max 30 Visits/Year Max 30 Visits/Year Max 30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
‐ Generic Formulary $5 or $15 Copay $5 or $15 Copay + 50% $10 Copay
‐ Brand Name Formulary $30 Copay $30 Copay + 50% $20 Copay
‐ Non‐Formulary $50 Copay $50 Copay + 50% N/A
‐ Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
‐ Generic Formulary $12.50 or $37.50 Copay Not Covered $20 Copay
‐ Brand Name Formulary $90 Copay Not Covered $40 Copay
‐ Non‐Formulary $150 Copay Not Covered N/A
‐ Supply Limit 90 Days N/A 90 Days

*An addi onal $500 copay will be assessed if pre‐authoriza on is not obtained.

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