Page 6 - Marcus & Millichap EE Guide 2020

Medical Benefits - Non-California

Kaiser Anthem Anthem
Plan Features
OR & CO - HMO Non-CA - Exclusive Classic PPO Non-CA - Classic PPO
Network Network BlueCard Non-Network BlueCard Non-Network
Health Benefits

Lifetime Maximum Benefit Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $3,500 $250 $750
- Family $0 $0 $7,000 $750 $2,250
Co-Insurance (Plan Pays) 100% 80% 50% after Ded 80% after Ded 60% after Ded

Office Visit Copay
- Primary Care Physician $10 Copay $30 Copay 50% $20 Copay 60%
- Specialist Office Visit $20 Copay $30 Copay 50% $20 Copay 60%
- Online Visit $0 Copay $10 Copay 50% $10 Copay 60%
(Live Health App) (Live Health App)
Out-of-Pocket Maximum
- Individual $2,000 $2,500 $10,000 $2,500 $7,500
- Family $4,000 $5,000 $20,000 $5,000 $15,000
Hospitalization
- Inpatient $100/admit $500 Copay 50%, Max $1,000 80% 60%, Max $1,000
Ben/Day Ben/day
- Outpatient $50 Copay $250 Copay 50%, Max $350 80% 60%, Max $350
Ben/Admit Ben/Admit

Lab and X-Ray (Advanced $10 Copay (OR) 100% 50% 80% 60%
Imaging may vary) 100% (CO)
Emergency Services $150 Copay (OR) $100 Copay $150 Copay, 80%
$100 Copay (CO)
Urgent Care $20 Copay $30 Copay 50% $20 Copay 60%

Preventive Care 100% 100% 50% 100% 60%
Chiropractic $30 Copay 50% $20 Copay 60%
Not Covered
Max 30 Visits/Year Max 30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
- Tier 1 (a or b) Generic: $10 $5 T1a / $20 T1b $5 or $20 + 50% 1 $5 T1a / $20 T1b $5 or $20 + 50% 1
1 1
- Tier 2 Brand: $20 $30 Copay $30 Copay + 50% $30 Copay $30 Copay + 50%
- Tier 3 N/A (OR)/ $20 (CO) $50 Copay $50 Copay + 50% 1 $50 Copay $50 Copay + 50% 1
- Tier 4 20% Max $250 (CO) 30% Max $250 30% max $250 30% Max $250 30% Max $250
- Kaiser Self-Injectables 20% (OR) N/A N/A N/A N/A
- Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 (a or b) Generic: $20 $12.50 T1a / Not Covered $12.50 T1a / Not Covered
$50 T1b $50 T1b
- Tier 2 Brand: $40 $90 Copay Not Covered $90 Copay Not Covered
- Tier 3 N/A (OR)/ $40 (CO) $150 Copay Not Covered $150 Copay Not Covered
- Tier 4 N/A 30% Max $250 Not Covered 30% Max $250 Not Covered
- Supply Limit 90 Days 90 Days N/A 90 Days N/A
1. Copay + 50% of the remaining Rx drug max allowed & costs in excess of Rx drug max allowed.

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