Page 5 - ENCO Benefits Guide 01-18 revised EAP

BENEFITS

MEDICAL INSURANCE

ANTHEM BLUE CROSS ANTHEM BLUE CROSS ANTHEM BLUE CROSS
PLAN NAME SELECT HMO FULL HMO PPO
Network Name Select HMO California Care HMO Prudent Buyer PPO Non-Network
or Blue Card
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $200 $400
- Family $0 $0 $600 $800
Co-Insurance (Plan Pays) 100% 100% 90% 50%
Office Visit Copay
- Primary Care Physician $10 Copay $10 Copay $10 Copay Deductible, 50%
- Specialist Office Visit $30 Copay $30 Copay $30 Copay Deductible, 50%

Out-of-Pocket Maximum
- Individual $2,000 $2,000 $3,000 $6,000
- Family $4,000 $4,000 $6,000 $12,000

Hospitalization
- Inpatient $250 Copay/day for 3 $250 Copay/day for 3 Deductible, 10% Deductible, 50%
days days
- Outpatient $100/admission $100/admission Deductible, 10% Deductible, 50%
Emergency Services $100 Copay $100 Copay Deductible, $200 Copay, 10%

Urgent Care $10 Copay $10 Copay $20 Copay Deductible, 50%
Preventive Care 100% 100% 100% Deductible, 50%
Chiropractic $10 Copay $10 Copay 50% Not Covered

20 Visits/Year 20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1a/1b $5/$15 Copay $5/$15 Copay $5/$15 Copay Not Covered
- Tier 2 $35 Copay $35 Copay $35 Copay Not Covered
- Tier 3 $70 Copay $70 Copay $70 Copay Not Covered
- Tier 4 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b $13/$38 Copay $13/$38 Copay $13/$38 Copay Not Covered
- Tier 2 $105 Copay $105 Copay $105 Copay Not Covered
- Tier 3 $210 Copay $210 Copay $210 Copay Not Covered
- Tier 4 (30 days only) 30% Max $250 Copay 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

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