Page 7 - Career Group Guide 2020 - CA (SF) Full Time

Medical Plan Highlights

Anthem Blue
Anthem Blue Cross Cross Anthem Blue Cross
Plan Name Deductible HMO EPO PPO

Blue Cross HMO Blue Cross PPO Blue Cross PPO
(CA Care) Large (Prudent Buyer) (Prudent Buyer)
Network Name Group Large Group Large Group Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $500 per person $1,000 $750 $2,250
- Family $3,000 $2,250 $6,750
Out-of-Pocket Maximum
- Individual $3,000 $5,500 $5,000 $15,000
- Family $6,000 $11,000 $10,000 $30,000

Co-Insurance (Plan Pays) 80% 80% 80% 60%

Office Visit Copay
- Preventive Care No Charge No Charge No Charge Deductible, 40%
- Primary Care Physician $20 Copay $20 Copay $30 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $40 Copay $50 Copay Deductible, 40%
- Urgent Care $20 Copay $20 Copay $30 Copay Deductible, 40%
- Telemedicine $10 Copay $10 Copay $10 Copay Deductible, 40%

Hospitalization
- Inpatient Deductible, 20% Deductible, 20% Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% Deductible, 20% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic No Charge Deductible, 20% Deductible, 20% Deductible, 40%
- Complex $100 Copay Deductible, 20% Deductible, 20% Deductible, 40%
Emergency Services Deductible,$150 Deductible,$150 Deductible,$150 Copay, 20%
Copay, 20% Copay, 20%

Chiropractic $20 Copay $20 Copay $30 Copay Deductible, 40%
60 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible None None None None
Retail Pharmacy
- Generic Formulary $5/$20 Copay $5/$20 Copay $5/$20 Copay 50% to $250
- Brand Name Formulary $40 Copay $40 Copay $30 Copay 50% to $250
- Non-Formulary $75 Copay $60 Copay $50 Copay 50% to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $12.50/$50 Copay $12.50/$50 Copay $12.50/$50 Copay Not Covered
- Brand Name Formulary $120 Copay $120 Copay $90 Copay Not Covered
- Non-Formulary $225 Copay $180 Copay $150 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

Employee Benefits 7