Page 13 - HM Benefits Guide 2019 CA

Medical Plans

Anthem Blue Cross Kaiser Permanente
PPO (High) HMO
Network Name PPO (Prudent Buyer) Non-Network Kaiser Facilities Only
Health Benefits
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $500 $1,500 $0
• Family $1,500 $4,500 $0
Out-of-Pocket Maximum
• Individual $3,500 $10,500 $1,500
• Family $7,000 $21,500 $3,000
Coinsurance (You Pay) 20% 40% 0%
Physician Office Visit
• Preventive Care No Charge Deductible, 40% No Charge
• PCP $20 Copay Deductible, 40% $20 Copay
• Specialist $40 Copay Deductible, 40% $35 Copay
• Urgent Care $20 Copay Deductible, 40% $20 Copay
• Telemedicine $10 Copay N/A No Charge
Hospitalization
• Inpatient Deductible, 20% Deductible, 40%* $250 Copay
• Outpatient Surgery Deductible, 20% Deductible, 40%* $35 Copay
Emergency Services $150 Copay, 20% $100 Copay
Chiropractic $20 Copay Deductible, 40% $15 Copay
30 Visits/Year 30 Visits/Year 20 Visits/Year
Pharmacy Benefits
Retail Pharmacy
• Tier 1a / 1b $5 / $15 Copay 50% Max $250 $10 Copay
• Tier 2 $30 Copay 50% Max $250 $35 Copay
• Tier 3 $50 Copay 50% Max $250 N/A
• Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
50
• Tier 1a / 1b $12 / $37 Copay Not Covered $20 Copay
50
• Tier 2 $90 Copay Not Covered $70 Copay
• Tier 3 $150 Copay Not Covered N/A
• Supply Limit 90 Days N/A 100 Days
Specialty
• Tier 4 30% Max $250 50% Max $250 20% Max $150
• Supply Limit 30 Days (Retail / 30 Days (Retail Only) 30 Days (Retail / M.O.)
M.O.)
*Limitations apply. See SBC for details.

Benefits Book | 13