Page 6 - Evisions Benefit Guide 2020 - Effective 1.1.2020

Benefits

Medical Insurance - Available to California Employees Only

Kaiser Permanente Blue Shield Blue Shield
Plan Name HMO HMO Trio HMO Full
Network Name Kaiser Permanente Trio ACO HMO Access+ HMO
Network Limited Network Full Network
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $0
- Family Member $0 $0 $0
- Family $0 $0 $0
Co-Insurance (Plan Pays) 100% 100% 100%

Office Visit Copay
- Primary Care Physician $25 Copay $25 Copay $40 Copay
- Specialist Office Visit $25 Copay $25 Copay $40 Copay
Out-of-Pocket Maximum
- Individual $1,500 $2,500 $3,000
- Family Member $1,500 $2,500 $3,000
- Family $3,000 $5,000 $6,000
Hospitalization
- Inpatient $500 Copay $750 Copay $1,000 Copay
- Outpatient $150 Copay $100-$400 Copay $200-$500 Copay
Emergency Services $100 Copay $150 Copay $150 Copay

Urgent Care $25 Copay $25 Copay $40 Copay
Preventive Care 100% 100% 100%
Chiropractic $10 Copay $10 Copay $10 Copay

30 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0 $0
- Family $0 $0 $0

Retail Pharmacy
- Tier 1 $10 Copay $15 Copay $15 Copay
- Tier 2 $25 Copay $30 Copay $30 Copay
- Tier 3 N/A $45 Copay $45 Copay
- Tier 4 20% Max $150 Copay 20% Max $200 Copay 20% Max $200 Copay
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $20 Copay $30 Copay $30 Copay
- Tier 2 $50 Copay $60 Copay $60 Copay
- Tier 3 N/A $90 Copay $90 Copay
- Tier 4 N/A 20% Max $400 Copay 20% Max $400 Copay
- Supply Limit 100 Days 90 Days 90 Days

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