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Medical Benefits

Anthem Blue Cross | BASE - HMO

With the Anthem Blue Cross Health Maintenance Organization (HMO) plan, you must choose a primary care physician (PCP)
or medical group within the Traditional Full HMO network. This base plan, provides you the more affordable premium when
it comes to your payroll deductions.

When you get care, you'll pay the full charges for covered services until you reach a set amount known as your deductible.
After you reach your deductible, you'll start paying less – a copay or a percentage of the charges (a coinsurance) for the rest
of the year. Full charges, copays, and coinsurance count toward your out-of-pocket maximum, which helps limit how much
you pay for care. After you reach your out-of-pocket maximum, you won't have to pay for most covered services for the rest
of the year.

Your HMO plan includes a Chiropractic Care and Acupuncture Rider Plan 10/30, meaning you have direct access to these
specialists at a low cost of $10/visits, up to 30 visits a year.

Anthem Blue Cross | PUSH - H.S.A

With the H.S.A. plan, you can pay for qualified healthcare expenses now and grow your savings for future healthcare needs.
This plan combines a High Deductible Health Plan (HDHP) with a special, tax-qualified Health Savings Account (HSA). You can
contribute tax-free money to your HSA up to IRS maximums. The money in your account is yours to pay for current
healthcare expenses - or you can save for future healthcare expenses. Similar to the PPO plan, you have the freedom to
choose your doctor without the requirement of selecting a PCP and you may self-refer to specialists. You may use a Prudent
Buyer PPO network provider whose negotiated rates provide richer levels of benefits with claim forms filed by the
providers. If you obtain services using a non-network provider, please note that you will be responsible for the difference
between the covered amount and the actual charges, and you may be responsible for filing claims.

Anthem Blue Cross | ALL OUT - PPO

The PPO plan allows you to direct your own care. If you receive care from a physician who is a member of the network, a
greater percentage of the entire cost will be paid by the insurance plan. However, you are not limited to the physicians
within the network and you may self-refer to specialists. If you obtain services using a non-network provider, please note
that you will be responsible for the difference between the covered amount and the actual charges, and you may be
responsible for filing claims.

Finding In-Network Medical Providers
Go to www.anthem.com/find-doctor or call (800) 888-8222
 HMO: Refer to the Blue Cross HMO (CACare) - Large Group network
 HSA: Refer to the Prudent Buyer PPO network
 PPO: Refer to the Prudent Buyer PPO network

Summary of Benefits and Coverage (SBC)
Health insurance issuers and group health plans are required to provide you with an easy-to-understand summary about your
health plan’s benefits and coverage, referred to as a Summary of Benefits and Coverage (SBC). This guide is designed to help
you understand the medical plan options offered to you by West Coast Fitness LLC (Orangetheory® Fitness). Please refer to
the SBC and carrier contracts provided by Anthem Blue Cross for additional plan details.

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