Page 4 - Coast Sign Benefit Summary 2017 Final 9.26.17

Medical Options

Anthem Select HMO / SIMNSA Medical Plan: Anthem offers a Health Maintenance Organization (HMO) that
provides access to healthcare in California as well as across the Mexican border. Under the California HMO, you must choose a
Primary Care Physician (PCP). All of your care must be directed through your PCP. You will receive benefits only if you use the
doctors, clinics and hospitals that belong to the medical group in which you are enrolled. If you choose SIMNSA as your medical
group, you are entitled to different schedule of benefits.

Kaiser HMO Medical Plan: With the Kaiser Health Maintenance Organization (HMO) plan, services must be obtained at a
Kaiser facility, except in the case of emergency. Kaiser integrates all elements of healthcare such as physicians, medical centers,
pharmacy and administration in one convenient facility. In addition, Kaiser offers online tools so you can email your doctor’s office,
make appointments, refill prescriptions, and more.

Anthem Kaiser
Plan Features Select / SIMNSA HMO Medical HMO Medical Plan
Plan
Network Name SIMNSA (Mexico) Select HMO Kaiser Only
(California)

Deductible (Annual)
- Individual / Family None None
Co-Insurance (You Pay) N/A N/A N/A
Physician Office Visit $5 Copay $35 Copay $30 Copay
($45 Copay Specialist)
Out of Pocket Maximum
- Individual / Family $3,500 / $7,000 $3,000 / $6,000

Hospitalization
- Inpatient No Charge $750/Day (3 Day Max) $500/Day
- Outpatient Surgery No Charge $375 Copay $250/Procedure
Lab and X-Ray No Charge No Charge ($100 $10 Copay ($50 Complex)
Copay Complex)
Emergency Services $100 Copay $150 Copay $150 Copay
Urgent Care $25 Copay $35 Copay $30 Copay

Preventive Care No Charge No Charge
Chiropractic $5 Copay $35 Copay Not Covered
(Limit 60 Days)
Mental Health
- Inpatient No Charge $750/Day (3 Day Max) $500/Day
- Outpatient $5 Copay $35 Copay $30 Copay
Prescription Drugs - Copay SIMNSA Only
- Deductible None $150 Member / None
$450 Family
- Tier 1 $5 Copay $5/$20 Copay $10 Copay
- Tier 2 $5 Copay $40 Copay $30 Copay
- Tier 3 $5 Copay $60 Copay N/A
- Mail Order (90 Day Supply) $5 Copay $12.50/$50 / $120 / $20 / $60 / N/A
$180
Finding an Anthem Select HMO Provider - Go to www.anthem.com/ca or call 800-888-8288 to find a provider near you. Select HMO
participants should refer to the “Select HMO” network when prompted.
Finding a Kaiser HMO Provider - Go to www.kp.org or call (800) 464-4000 to find a provider near you.
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