Page 6 - 360 Behavioral Health Guide 2018-2019 Final

Medical Benefits

Anthem Blue Cross Anthem Blue Cross Kaiser Permanente
Plan Name
Classic HMO (Select) Classic HMO (Traditional) HMO
Blue Cross HMO
Network Name Select HMO Kaiser HMO Network
(CACare)— Large Group
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $0 $0 $500
- Family $0 $0 $1,000

Co-Insurance (Plan Pays) 100% 100% 90%

Office Visit Copay
- Primary Care Physician $30 Copay $30 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay $20 Copay

Out-of-Pocket Maximum
- Individual $2,500 $2,500 $3,000
- Family $5,000 $5,000 $6,000

Hospitalization
- Inpatient $500 Copay $500 Copay 10% after deductible
- Outpatient $250 Copay $250 Copay 10% after deductible

Lab and X-Ray 100% 100% $10 Copay

Emergency Services $100 Copay $100 Copay 10% after deductible
Urgent Care $30 Copay $30 Copay $20 Copay

Preventive Care 100% 100% 100%
Chiropractic $30 Copay $30 Copay N/A

60 Day Limit/Year 60 Day Limit/Year N/A

Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0 $0
- Family $0 $0 $0

Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay $10 Copay
- Brand Name Formulary $30 Copay $30 Copay $30 Copay
- Non-Formulary $50 Copay $50 Copay $30 Copay
- Specialty $50 Copay $50 Copay 20% up to $200
Mail Order Pharmacy
- Generic Formulary $30 Copay $30 Copay $20 Copay
- Brand Name Formulary $60 Copay $60 Copay $60 Copay
- Non-Formulary $100 Copay $100 Copay $60 Copay

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