Page 7 - Benefit Guide 2019.2020 - Final

MEDICAL INSURANCE

ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME PRIORITY SELECT HMO FULL NETWORK HMO

Network Name Priority Select HMO California Care HMO

HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Single $0 $0
- Per Member $0 $0
- Per Family $0 $0
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay
- LiveHealth Online Telemedicine $49 Copay $49 Copay
Out-of-Pocket Maximum
- Single $2,500 $2,500
- Per Member N/A N/A
- Per Family $5,000 $5,000
Hospitalization
- Inpatient $250 Copay per Admission $250 Copay per Admission
- Outpatient $125 Copay per Admission $125 Copay per Admission
Lab and X-Ray
- Diagnostic No Charge No Charge
- Advanced Imaging $100 Copay per Test $100 Copay per Test
Emergency Services $150 Copay $100 Copay
Urgent Care $20 Copay $20 Copay
Preventive Care No Charge No Charge
Chiropractic $20 Copay $20 Copay
60-Day Limit per Benefit Period 60-Day Limit per Benefit Period
Pediatric Dental Not Covered Not Covered
PHARMACY BENEFITS

Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Tier 1a / 1b (30 Day Supply) $5 / $20 Copay $5 / $20 Copay
- Tier 2 (30 Day Supply) $30 Copay $30 Copay
- Tier 3 (30 Day Supply) $50 Copay $50 Copay
- Tier 4 (30 Day Supply) 30% Max $250 Copay 30% Max $250 Copay
Mail Order Pharmacy
- Tier 1a / 1b (90 Day Supply) $12 / $50 Copay $12 / $50 Copay
50
50
- Tier 2 (90 Day Supply) $90 Copay $90 Copay
- Tier 3 (90 Day Supply) $150 Copay $150 Copay
- Tier 4 (30 Day Supply) 30% Max $250 Copay 30% Max $250 Copay

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