Page 5 - Coast Sign Benefit Summary 2017 Final 9.26.17

Medical Options

Anthem HMO Medical Plan: With the Anthem Health Maintenance Organization (HMO) plan, you must choose a
primary care physician (PCP) or medical group within the traditional HMO network, Blue Cross HMO (CACare) Large Group. All of
your care must be directed through your PCP or medical group. Any specialty care you need will be coordinated through your PCP
and will generally require a referral or authorization. You will receive benefits only if you use the doctors, clinics and hospitals that
belong to the medical group in which you are enrolled, except in the case of an emergency.

Anthem PPO Medical Plan: The Anthem Preferred Provider Organization (PPO) plan allows you to direct your own care.
You are not limited to the physicians within the PPO network and you may self-refer to specialists. If you receive care from a
physician who is a member of the PPO network, a greater percentage of the entire cost will be paid by the insurance plan. You may
also obtain services using a non‐network provider; however, you will be responsible for the difference between the covered
amount and the actual charges and you may be responsible for filing claims.

Anthem Anthem
Plan Features
HMO Medical Plan PPO Medical Plan

Network Name Blue Cross HMO (CACare) - Large Blue Cross PPO Non-Network
Group (Prudent Buyer) - Large
Group
Deductible (Annual)
- Individual / Family None $250 / $750 $750 / $2,250

Co-Insurance (You Pay) N/A 20% 40%
Physician Office Visit $30 Copay $20 Copay Ded, 40%
(Ded Waived)

Out of Pocket Maximum
- Individual / Family $2,500 / $5,000 $2,500 / $5,000 $7,500 / $15,000

Hospitalization
- Inpatient $500/Admit Ded, 20% $500 Copay, Ded, 40%
- Outpatient Surgery $250 Copay Ded, 20% Ded, 40%
Lab and X-Ray No Charge ($100 Complex) Ded, 20% Ded, 40%

Emergency Services $100 Copay Ded, $150, 20%
Urgent Care $30 Copay $20 Copay Ded, 40%
(Ded Waived)

Preventive Care No Charge No Charge Ded, 40%
Chiropractic $30 Copay $20 Copay Ded, 40%
(Limit 60 Days) (Limit 30 visits) (Limit Combined)

Mental Health
- Inpatient $500/Admit Ded, 20% Ded, 40%
- Outpatient $30 Copay $20 (Ded Waived) Ded, 40%
Prescription Drugs - Copay
- Deductible None None None
- Tier 1 $10 Copay $5/$15 Copay 50%
- Tier 2 $30 Copay $30 Copay 50%
- Tier 3 $50 Copay $50 Copay 50%
- Mail Order (90 day supply) $25 / $90 / $150 $12.50/$37.50 / $90 / Not Covered
$150

Finding an Anthem HMO Provider - Go to www.anthem.com/ca or call 800-888-8288 to find a provider near you. HMO participants should
refer to the “Blue Cross HMO (CACare) - Large Group” network when prompted.
Finding an Anthem PPO Provider - Go to www.anthem.com/ca or call 800-888-8288 to find a provider near you. PPO participants should
refer to the “Blue Cross PPO (Prudent Buyer) - Large Group” network when prompted. 5