Page 10 - Incipio EE Guide 01-19 CA Semi-Monthly

BENEFITS

Medical Insurance

ANTHEM KAISER
PLAN NAME HMO HMO
NETWORK NAME Full HMO (CA Care) Kaiser Permanente
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual None None
- Family None None
Co-Insurance (You Pay) N/A N/A

Office Visit Copay
- Primary Care Physician $35 Copay $30 Copay
- Specialist Office Visit $50 Copay $50 Copay
- Virtual Visit $49 Copay No Charge
Out-of-Pocket Maximum
- Individual $4,500 $3,500
- Family $9,000 $7,000

Hospitalization
- Inpatient $500/Day Copay, 3 Day Max $500/Day Copay
- Outpatient Surgery $250 Copay $250 Copay
Lab and X-Ray
- Diagnostic No Cost $10 Copay
- Advanced $100 Copay $100 Copay
Emergency Services $150 Copay $150 Copay
Urgent Care $35 Copay $30 Copay

Preventive Care No Charge No Charge
Chiropractic $35 Copay $15 Copay
60 Days Limit/Benefit Period 30 Visits/Year

Pharmacy Benefits
Pharmacy Deductible None None
Retail Pharmacy
- Tier 1a/1b $5/$15 Copay $15 Copay
- Tier 2 $30 Copay $35 Copay
- Tier 3 $50 Copay N/A
- Tier 4 30% Max $250 Copay 30% Max $200 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
50
50
- Tier 1a/1b $12 /$37 Copay $30 Copay
- Tier 2 $90 Copay $70 Copay
- Tier 3 $150 Copay N/A
- Tier 4 30% Max $250 Copay N/A
- Supply Limit 90 Days 100 Days
Please refer to the Summary of Benefits and Coverages (SBCs) provided by Anthem and Kaiser for additional plan
10 details. These documents are located on HR Connection.