Page 6 - Pathway EE Guide 06-20

BENEFITS

Medical Insurance

Anthem Anthem
Plan Name HMO HDHP
Network Name California Care HMO (CA Only) Prudent Buyer PPO Non-Network
Health Benefits (You Pay)
Lifetime Maximum Benefit Unlimited Unlimited

Deductible (Annual)
- Individual $500 per member $2,800 $8,400
- Family N/A $5,600 $16,800
Co-Insurance (Plan Pays) 100% 80% 60%
Office Visit Copay
- Primary Care Physician $20 Copay After Deductible, 20% After Deductible, 50%
- Specialist Office Visit $40 Copay After Deductible, 20% After Deductible, 50%
- Virtual Visits $49 (cash price) After Deductible, 20% N/A
Out-of-Pocket Maximum
- Individual $3,000 $5,000 $15,000
- Family $6,000 $10,000 $30,000

Hospitalization
- Inpatient 20% After Deductible, 20% After Deductible, 50%
- Outpatient Surgery 20% After Deductible, 20% After Deductible, 50%
Lab and X-Ray $0 office/lab After Deductible, 20% After Deductible, 50%
(After Ded., 20% outpatient)
$100 advanced (MRI, CT, etc.)
Emergency Services After Deductible, $150, 20% Deductible, $150, 20%

Urgent Care $20 Copay After Deductible, 20% After Deductible, 50%
Preventive Care No Charge No Charge Not Covered
Chiropractic $10 Copay After Deductible, 20% After Deductible, 45%
Max 30 Visits/Year Max 24 Visits/Year
Pharmacy Benefits (You Pay)

Pharmacy Deductible $0 Health Deductible Applies
Retail Pharmacy After Deductible After Deductible
- Tier 1a / Tier 1b $5/$20 Copay $5/$15 Copay 50%
- Tier 2 $40 Copay $50 Copay 50%
- Tier 3 $75 Copay $65 Copay 50%
- Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy After Deductible
- Tier 1a / Tier 1b $12.50/$50 Copay $12.50/$37.50 Copay Not Covered
- Tier 2 $120 Copay $150 Copay Not Covered
- Tier 3 $225 Copay $195 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A
Summary of Benefits and Coverage (SBC)

This guide is designed to help you understand the medical plan options offered to you by Pathway. Please refer to the SBC and
carrier contracts provided by Anthem for additional plan details.
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