Page 5 - Kagan Benefit Guide Out of CA.pub

Benefits

Medical Insurance

Anthem
PPO
In‐Network Non‐Network

Health Benefits
Life me Maximum Benefit Unlimited

Deduc ble (Annual)
‐ Individual $1,000 $3,000
‐ Family $3,000 $9,000

Co‐Insurance (Plan Pays) 80% a er Ded 60% a er Ded
Office Visit Copay
‐ Primary Care Physician $35 Copay 60%
‐ Specialist Office Visit $35 Copay 60%
Out‐of‐Pocket Maximum
‐ Individual $5,000 $15,000
‐ Family $10,000 $30,000

Hospitaliza on
‐ Inpa ent 80% 60%
‐ Outpa ent 80% 60%
Lab and X‐Ray (Plan Pays) 80% 60%
Emergency Services $150 Copay, then covered at 80%

Urgent Care $35 Copay 60%
Preven ve Care (Plan Pays) 100% 60%
Chiroprac c $35 Copay 60%

30 Visits/Year
Pharmacy Benefits

Pharmacy Deduc ble
‐ Individual $0 $0
‐ Family $0 $0
Retail Pharmacy
‐ Tier 1 $5 T1a / $20 T1b 50% up to $250
‐ Tier 2 $30 Copay 50% up to $250
‐ Tier 3 $50 Copay 50% up to $250
‐ Tier 4 30% up to $250 50% up to $250
‐ Supply Limit 30 Days 30 Days
Mail Order Pharmacy
‐ Tier 1 $12.50 T1a / $50 T1b Not Covered
‐ Tier 2 $90 Copay Not Covered
‐ Tier 3 $150 Copay Not Covered
‐ Tier 4 30% up to $250 Not Covered
‐ Supply Limit 90 Days N/A
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