Page 6 - BNDS EE Guide 19

BENEFITS

Medical Insurance

CalChoice CalChoice CalChoice CalChoice CalChoice

Sharp Sharp HMO Per-
Anthem Anthem Kaiser HMO Premier formance
Plan Name HMO Platinum HMO Gold HMO Platinum Platinum A Platinum B

Network Name Select HMO Select HMO Kaiser Premier Performance
Network Network Network Network Network
Health Benefits (BASE Plan)
Lifetime Max. Benefit Unlimited Unlimited Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $0 $0 $0 $0 $0
- Family $0 $0 $0 $0 $0
Out-of-Pocket Maximum
- Individual $2,000 $5,500 $3,000 $3,500 $3,000
- Family $4,000 $11,000 $6,000 $7,000 $6,000
Co-Insurance (Plan Pays) 100% 100% 100% 80% 85%

Office Visit Copay
- Preventive Care No Charge No Charge No Charge No Charge No Charge
- Primary Care Physician $15 Copay $30 Copay $10 Copay $15 Copay $15 Copay
- Specialist Office Visit $30 Copay $55 Copay $20 Copay $20 Copay $30 Copay
- Urgent Care $15 Copay $30 Copay $10 Copay $20 Copay $30 Copay
- Telemedicine $5 Copay $5 Copay $5 Copay N/A N/A
Hospitalization
- Inpatient $250/day, up to $600/day, up to $500 /admission $400 /admission 15% Coinsurance
$750 maximum $1,800 maximum
- Outpatient Surgery $200 /visit $500 /visit $300 Copay 20% coinsurance 15% Coinsurance
Lab and X-Ray
- Diagnostic (Lab, Xray) $15 -$25 Copay $25—$40 Copay $20 -$40 Copay No Charge No Charge
- Imaging (CT, PET, MRI) $150 /procedure $250 /procedure $150 /procedure $150 /procedure $100 /procedure
Emergency Services $200 Copay $300 Copay $200 Copay $150 Copay 15% coinsurance
Chiropractic $15 Copay $30 Copay $10 Copay Not Covered Not Covered
Limit 20 Visits Limit 20 Visits Limit 20 Visits
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0 $0
- Family $0 $0 $0 $0 $0
Retail Pharmacy
- Generic Formulary $5 - $15 Copay $5 -$20 Copay $5 Copay $10 Copay $10 Copay
- Brand Name Formulary $35 Copay $40 Copay $15 Copay $25 Copay $25 Copay
- Non-Formulary $70 Copay $80 Copay $15 Copay $50 Copay $50 Copay
- Specialty 30% up to $250 30% up to $250 10% up to $250 N/A N/A
- Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $13 -$38 Copay $13 -$50 Copay $10 Copay $20 Copay $20 Copay
- Brand Name Formulary $105 Copay $120 Copay $30 Copay $50 Copay $50 Copay
- Non-Formulary $210 Copay $240 Copay $30 Copay $100 Copay $100 Copay
- Specialty 30% up to $250 30% up to $250 30% up to $250 N/A N/A
- Supply Limit 90 Days 90 Days 100 Days 90 Days 90 Days

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