Page 5 - 2017 MegaPath Benefits Guide_FINALV2

BENEFITS

Health Plan Highlights

All Locations Northern California
Only
Anthem Blue Cross Kaiser Permanente
Plan Name PPO HMO
Network Network Non-Network Kaiser Facilities Only
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Deductible (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 Deductible, 30% $25 Copay
- Specialist Office Visit $20 Copay Deductible, 30% $25 Copay

Out-of-Pocket Maximum
- Individual $3,500 $10,500 $1,500
- Family $7,000 $21,000 $3,000
Hospitalization
- Inpatient Deductible, 10%* Deductible, 30%* $250 Copay

- Outpatient Deductible, 10% Deductible, 30% $25 Copay
Max $350 Benefit/Year
Lab and X-Ray Deductible, 10% Deductible, 30% No Charge

Emergency Services $150 Copay, 10% $150 Copay, 10% $100 Copay
Urgent Care $20 Copay Deductible, 30% $25 Copay
Preventive Care No Charge Deductible, 30% No Charge
Chiropractic $20 Copay Deductible, 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 additional $500 copay will be assessed if pre-authorization is not obtained.

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