Page 7 - KNCH Benefits Guide 2019 v3

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross
Plan Features HSA Solution PPO

Network CA: PPO Non-Network CA: PPO Non-Network
Non-CA: National PPO Non-CA: National PPO
HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited
Calendar Year Deductible
Individual $1,500 $4,500 $1,500 $4,500

Individual in a Family $2,700 $4,500 $1,500 $4,500
Family $3,000 $9,000 $3,000 $9,000
Coinsurance (Plan Pays) 90% 70% 80% 60%
Physician Office Visit
PCP Deductible, 90% Deductible, 70% $15 Copay Deductible, 60%
Specialist Deductible, 90% Deductible, 70% $15 Copay Deductible, 60%
Calendar Year Out-of-
Pocket Maximum
Individual $3,000 $9,000 $3,500 $10,500
Individual in a Family $3,000 $9,000 $3,500 $10,500
Family $6,000 $18,000 $7,000 $21,000
Hospitalization
Inpatient Deductible, 90% Deductible, 70% Deductible, 80% Deductible, 60%
Outpatient Deductible, 90% Deductible, 70% Deductible, 80% Deductible, 60%

Emergency Services Deductible, 90% Deductible, $150 copay, 80%
Urgent Care Deductible, 90% Deductible, 70% $15 Copay Deductible, 60%
Lab and X-Ray: Deductible, 90% Deductible, 70% Deductible, 80% Deductible, 60%
Preventive Care 100% Deductible, 70% 100% Deductible, 60%

Chiropractic Deductible, 90% Deductible, 70% $15 Copay Deductible, 60%
30 Visits/Year 30 Visits/Year

PHARMACY BENEFITS Full plan deductible must be met prior to
prescription copays
Retail (30 Day Supply)
Tier 1a / 1b $5 / $15 Copay $5 / $20 Copay
Tier 2 $40 Copay 50% up to $250 $40 Copay 50% up to $250
Tier 3 $60 Copay Copay per Script $60 Copay Copay per Script
Tier 4 $30% up to $250 Copay $30% up to $250 Copay

Mail Order (90 Day Supply)
Tier 1a / 1b $12.50 / $37.50 Copay $12.50 / $50 Copay
Tier 2 $120 Copay Not Covered $120 Copay Not Covered
Tier 3 $180 Copay $180 Copay
Tier 4 n/a n/a

FINDING A MEDICAL PROVIDER:

Go to anthem.com/ca. Note: if you are outside CA, you will then select the state you reside:
• (CA Employees) For PPO & HSA: Select “Blue Cross PPO (Prudent Buyer) - Large Group” or call (800) 888-8288
• (NON-CA Employees) For PPO & HSA: Select “National PPO (Blue Card PPO)” or call (866) 207-9878
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