Page 18 - open_enrollment_benefits_book_CA_2018_v1

Medical Insurance: Cost Comparison

ANTHEM HMO KAISER HMO ANTHEM PPO ANTHEM HSA PPO
Anthem Kaiser Anthem Non- Anthem Non-
Network Network Facilities Network Network Network Network
YOUR COST PER PAYCHECK

Just You $39 $31 $76 $37
• You + Spouse/Partner $85 $68 $166 $83
• You + Child(ren) $70 $56 $136 $68
• You + Family $121 $95 $233 $116
HEALTHCARE COSTS

Annual Deductible (Ded)
• Individual None None $0 $200 $1,500 $3,000
• Family None None $0 $600 $3,000 $6,000
Co-insurance N/A N/A 10% 30% 0% 30%

Physician Office Visit $20 $20 $10 Ded, 30% Ded, 0% Ded, 30%

Lab and X-Ray
• Routine No Charge $5 10% Ded, 30% Ded, 0% Ded, 30%
• Complex $100 $5 10% Ded, 30% Ded, 0% Ded, 30%

Out-of-Pocket Maximum Includes Ded Includes Ded Includes Ded
• Individual $1,500 $1,500 $500 $1,500 $3,000 $6,000
• Family $3,000 $3,000 $1,000 $3,000 $6,000 $12,000
Hospitalization
• Inpatient No Charge No Charge 10% Ded, 30% Ded, 0% Ded, 30%
• Outpatient Surgery No Charge $20 10% Ded, 30% Ded, 0% Ded, 30%

Emergency Services $100 $100 $100, 10% $100, Ded, 10% Ded, 0% Ded, 0%

Urgent Care $20 $20 $10 Ded, 30% Ded, 0% Ded, 30%
Wellness Exams No Charge No Charge No Charge Ded, 30% No Charge Ded, 30%

Hearing Aids 20% $2,500 20% Ded, 20% Ded, 20% Ded, 20%
(Medically Necessary) Allowance

Chiropractic $20 $10 $10 Ded, 30% Ded, 0% Ded, 30%
(60 Day Limit) (30 Visit Max) (30 Visit Max) (30 Visit Max)

Mental Health &
Substance Abuse
• Inpatient No Charge No Charge 10% Ded, 30% Ded, 0% Ded, 30%
• Outpatient $20 $20 $10 Ded, 30% Ded, 0% Ded, 30%

PHARMACY COSTS
Retail Pharmacy
(30 Day Supply) Ded, Plus Ded, Plus
• Tier 1 $10 $10 $5 $5 + 50% $10 30%
• Tier 2 $20 $30 $10 $10 + 50% $30 30%
• Tier 3 $40 N/A $10 $10 + 50% $50 30%

Mail Order
(90 Day Supply) Ded, Plus
• Tier 1 $10 $20 $5 Not Covered $10 Not Covered
• Tier 2 $40 $60 $20 Not Covered $60 Not Covered
• Tier 3 $80 N/A $20 Not Covered $100 Not Covered