Page 5 - Catasys Benefit Guide 2019-2020

Medical Benefits

Anthem Blue Anthem Blue Cross Anthem Blue Cross
Cross HMO PPO 250 PPO 1,500
(Only
available in
Medical Benefits California)

Network California Care Prudent Buyer PPO Non-Network Prudent Buyer PPO Non-Network
HMO
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual None $250 $750 $1,500 $4,500
- Family None $750 $2,250 $4,500 $9,000
Co-Insurance (Plan Pays) 100% 80% 60% 80% 60%

Office Visit Copay
- Primary Care Physician $30 Copay $20 Copay 60% $25 Copay 60%
- Specialist Office Visit $40 Copay $20 Copay 60% $25 Copay 60%
Lab and X-Ray 100% 80%/80% 60% 80%/80% 60%
Complex Radiology $100 Copay 80% 60% 80% 60%
(CT, MRI, PET)
Out-of-Pocket Maximum
- Individual $2,500 $2,500 $7,500 $5,000 $15,000
- Family $5,000 $5,000 $15,000 $10,000 $30,000

Hospitalization $500 Copay 80% 60% 80% 60%
(per admit) (Limited to (Limited to
$1,000 Per $1,000 Per
Day) Day)

Emergency Services $100 Copay $150 Copay + 80% $150 Copay + 80%
Urgent Care $30 Copay $20 Copay 60% $25 Copay 60%
Preventive Care 100% 100% 60% 100% 60%

Chiropractic $30 Copay $20 Copay 60% $25 Copay 60%
60 Visits/Benefit 30 Visits/Benefit Period 30 Visits/Benefit Period
Period
Acupuncture $30 Copay $20 Copay 60% $25 Copay 60%
20 Visits/Benefit Period 20 Visits/Benefit Period
Pharmacy Benefits

Retail Pharmacy
- Tier 1a /1b $5 or $15 Copay $5 or $15 Copay 50% $5 or $20 Copay 50%
- Tier 2 $30 Copay $30 Copay 50% $30 Copay 50%
- Tier 3 $50 Copay $50 Copay 50% $50 Copay 50%
- Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $12.50 or $37.50 $12.50 or $37.50 Not Covered $12.50 or $50 Not Covered
- Tier 2 $90 Copay $90 Copay Not Covered $90 Copay Not Covered
- Tier 3 $150 Copay $150 Copay Not Covered $150 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A 90 Days N/A
Deductible - Ind./Family None None N/A None N/A

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