Page 5 - ENCO Benefits Guide 01-20_FINAL

BENEFITS

MEDICAL INSURANCE

ANTHEM BLUE CROSS ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME SELECT HMO FULL HMO PPO
Network Name Select HMO California Care HMO Prudent Buyer PPO Non-Network
or Blue Card
Health Benefits
Deductible (Annual)
- Individual $0 $0 $250 $2,000
- Family $0 $0 $750 $4,000

Co-Insurance (Plan Pays) 100% 100% 90% 50%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay $15 Copay Deductible, 50%
- Specialist Office Visit $30 Copay $30 Copay $30 Copay Deductible, 50%
- Retail Health Clinic Visit $20 Copay $20 Copay $15 Copay Deductible, 50%
- LiveHealth Online 1st 3 visits free, $5 1st 3 visits free, $5 there- 1st 3 visits free, $5 Deductible, 50%
thereafter after thereafter
Out-of-Pocket Maximum
- Individual $2,000 $2,000 $4,000 $8,000
- Family $4,000 $4,000 $8,000 $16,000

Hospitalization
- Inpatient $250 Copay/day $250 Copay/day Deductible, 10% Deductible, 50%
up to 3 days/admit Up to 3 days/admit
- Outpatient $150 Copay/visit $150 Copay/visit Deductible, 10% Deductible, 50%
Emergency Services $250 Copay $250 Copay Deductible, $200 Copay, 10%

Urgent Care $20 Copay $20 Copay $30 Copay Deductible, 50%
Preventive Care 100% 100% 100% Deductible, 50%
Chiropractic $20 Copay $20 Copay 50% Not Covered

20 Visits/Year 20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1 $15 Copay $15 Copay $10 Copay Not Covered
- Tier 2 $35 Copay $35 Copay $35 Copay Not Covered
- Tier 3 $70 Copay $70 Copay $70 Copay Not Covered
- Tier 4 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $38 Copay $38 Copay $25 Copay Not Covered
- Tier 2 $105 Copay $105 Copay $105 Copay Not Covered
- Tier 3 $210 Copay $210 Copay $210 Copay Not Covered
- Tier 4 (30 days only) 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
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