Page 6 - Inglewood USD Benefits Guide 2019 - Retiree_FINAL

BENEFITS

Retiree Cost $$ $$ $ $ $
Option 1 Option 2 Option 3 Option 4 Option 5

Kaiser Kaiser Anthem 10/100% Anthem 15/30 Anthem 30/40
Plan Name $10 HMO $20 HMO Vivity HMO Select HMO Vivity HMO

Network Name Kaiser Facilities Kaiser Facilities Vivity Select Vivity
Network Size A A AA AAA AA
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $0 $0 $0
- Family $0 $0 $0 $0 $0
Out-of-Pocket Maximum
- Individual $1,500 $1,500 $1,000 $1,500 $3,000
- Family $3,000 $3,000 $2,000 $3,000 $6,000
Co-Insurance (Plan Pays) 100% 100% 100% 100% 100%

Office Visit Copay
- Preventive Care No Charge No Charge No Charge No Charge No Charge
- Primary Care Physician $10 Copay $20 Copay $10 Copay $15 Copay $30 Copay
- Specialist Office Visit $10 Copay $20 Copay $30 Copay $30 Copay $40 Copay
- Urgent Care $10 Copay $20 Copay $30 Copay $15 Copay $30 Copay
Hospitalization
- Inpatient No charge No charge No charge $250 / admit $500 / day, 3
day max
- Outpatient $10 Copay $20 Copay No charge Hosp $150; FSC $250 Copay
$100
Lab and X-Ray
- Diagnostic No Charge No Charge No Charge No Charge No Charge
- Complex No Charge No Charge $100 Copay $100 Copay $100 Copay

Emergency Services $35 Copay $50 Copay $100 Copay $100 Copay $150 Copay
Chiropractic $10 Copay $10 Copay $10 Copay $10 Copay $10 Copay
40 Visits/Year 40 Visits/Year 30 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0 $0
- Family $0 $0 $0 $0 $0
Retail Pharmacy
- Tier 1 (Generic) $5 Copay $10 Copay $5 Copay $10 Copay $15 Copay
- Tier 2 (Brand-Name) $10 Copay $20 Copay $10 Copay $20 Copay $30 Copay
- Tier 3 (Non-Formulary) N/A N/A $25 Copay $35 Copay $45 Copay
- Supply Limit 100 Days 100 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 (Generic) $5 Copay $10 Copay $10 Copay $20 Copay $30 Copay
- Tier 2 (Brand-Name) $10 Copay $20 Copay $20 Copay $40 Copay $60 Copay
- Tier 3 (Non-Formulary) N/A N/A $50 Copay $70 Copay $90 Copay
- Supply Limit 100 Days 100 Days 90 Days 90 Days 90 Days

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