Page 10 - Optima Tax EE Guide 01-20 AZ
P. 10

Medical Plan Highlights







                                                                               Anthem
         Plan Name                                                            Basic PPO
                                                           National PPO
         Network Name                                     (Blue Card PPO)                   Non-Network*
         Plan Differences
         Employee Premiums                                                        $
         Employee Cost Sharing                                         Contribution, Deductible,
                                                                          Copay, Coinsurance

         Network
          - Network Size                                                        
          - In-Network Benefits                                                   ✓
          - Non-Network Benefits                                                  ✓
         Access to Providers                                               Managed by You
         Health Benefits
         Lifetime Max Benefit                                                 Unlimited
         Deductible (Cal Year)
          - Individual                                                          $1,500
          - Family                                                              $3,000
         Out-of-Pocket Maximum
          - Individual                                         $6,000                          $12,000**
          - Family                                             $12,000                         $24,000**
         Coinsurance (Plan Pays)                                80%                               50%
         Office Visit Copay
          - Preventive Care                                  No Charge                        Not Covered
          - PCP                                              $30 Copay                      Deductible, 50%
          - Specialist                                       $40 Copay                      Deductible, 50%
          - Urgent Care                                      $30 Copay                      Deductible, 50%
          - Retail Clinic                                    $15 Copay                      Deductible, 50%
          - Virtual Visits: LiveHealth Online                 $5 Copay                            N/A
         24/7 Nurseline                                      No Charge                            N/A
         Hospitalization
          - Inpatient                                      Deductible, 20%                 Deductible, 50%***
          - Outpatient Surgery                             Deductible, 20%                 Deductible, 50%***
         Lab and X-Ray
          - Diagnostic                                     Deductible, 20%                 Deductible, 50%***
          - Radiological/Nuclear                           Deductible, 20%                 Deductible, 50%***

         Emergency Room Services                                                 20%
         Chiropractic                                        $40 Copay                      Deductible, 50%
         Max 20 Visits/Year
         Acupuncture                                         $40 Copay                      Deductible, 50%
         Max 20 Visits/Year

         *Out of network providers are reimbursed by our plan at Anthem Fee Schedule.

         **The out-of-pocket max, is the most you may pay in a year for covered services. Premiums, balance-billing charges,
         health care this plan doesn’t cover & penalties for failure to obtain pre-authorization for services is NOT included in the
         out-of-pocket limit.

         *** Additional coverage maximums apply to Non-Network providers. Please refer to plan documents for more details.

    10  Employee Benefits
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