Page 6 - JFSLA - Benefits Guide 2018-2019 (5.29.18)

Benefits

Medical Insurance

Carrier Anthem Anthem

Vivity Classic Classic
Plan Name
30/40/500 Admit HMO 20/40/250 Admit HMO

Network Name Anthem Vivity Network Anthem California Care HMO

Medical Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Annual Deductible
- Individual $0 $0
- Family $0 $0
Co-Insurance (Plan Pays) 100% 100%

Office Visit Copay
- Primary Care Physician $30 Copay $20 Copay
- Specialist Office Visit $40 Copay $40 Copay
Out-of-Pocket Maximum
- Individual $2,500 $2,000
- Family $5,000 $4,000
Hospitalization
- Inpatient $500 / Admit $250 / Admit
- Outpatient Surgery $250 / Admit $125 / Admit

Emergency Services $100 Copay $100 Copay
Urgent Care $30 Copay $20 Copay
Preventive Care 100% 100%

LiveHealth Online $49 Copay $49 Copay
Pharmacy Benefits

Retail Pharmacy (30 Days)
- Tier 1a / 1b $5 / $15 Copay $5 / $15 Copay

- Tier 2 $30 Copay $30 Copay
- Tier 3 $50 Copay $50 Copay
Mail-Order Pharmacy (90 Days)
- Tier 1a / 1b $12.50 / $37.50 Copay $12.50 / $37.50 Copay

- Tier 2 $90 Copay $90 Copay
- Tier 3 $150 Copay $150 Copay
Note: For all HMO plans, the Self-injectables/Specialty prescriptions will move from coverage under the medical plan to the pharmacy plan.

Finding a Medical Provider
www.anthem.com/ca: From the Anthem website, scroll down and click on the blue link labeled “Find a doctor>.” Next, under “Search as
Guest?” click on “Search by Selecting a Plan or Network.” Under “What type of care are you searching for?” select “Medical.” Under “What
state do you want to search in?” select your state of residence, and under Select a plan/network, select the network listed under
“Medical—Employer Sponsored.” Refer to the applicable network names (shown above and also on page 5 of this guide) when you are
prompted to select a plan. You may search by name or specialty under “Whose name is:” and “Who specializes in:” When searching for a
PCP check the box for “Able to serve as a Primary Care Physician.”

6