Page 6 - Community Health Systems Guide 2020 v2 (CHSI Review)

Medical Benefits

Anthem Blue Cross Kaiser Permanente
Plan Name HMO 20/40/250 admit/125 OP Traditional HMO Plan
Network California Care HMO Kaiser Permanente

Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual) None None
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay
- Specialist Office Visit $40 Copay $20 Copay
- Online Visit $10 Copay n/a

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

Hospitalization
- Inpatient $250 per admission $250 per admission
- Outpatient $125 copay per admission $100 copay per admission
Lab and X-Ray No charge $10 per encounter

Emergency Services $100 Copay per visit $100 Copay per visit
Urgent Care $20 Copay $20 Copay
Preventive Care No Charge No Charge
Chiropractic / Acupuncture $20 Copay $15 Copay

Pharmacy Benefits
Pharmacy Deductible None None

Retail Pharmacy
- Tier 1A / Tier 1B $5 / $15 Copay $15 Copay
- Tier 2 $30 Copay $30 Copay
- Tier 3 $50 Copay $30 Copay
- Tier 4 30% up to $250 30% up to $200
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1A / Tier 1B $12.50 / $37.50 Copay $30 Copay
- Tier 2 $90 Copay $60 Copay
- Tier 3 $150 Copay $60 Copay
- Tier 4 30% up to $250 30% up to $200
- Supply Limit 90 Days 90 Days

Chiropractic / Acupuncture
All plans, utilize the same network: American Specialty Health Plans of California, Inc. (ASH Plans)
Find an ASH Plans Participating Provider near you:
• Go to ashlink.com/ash or
• Call 1-800-678-9133 (TTY 711), Monday through Friday, from 5 a.m. to 10 p.m.

Video – Learn About Medical Plan Terms
Medical plan terms, such as deductibles, copays, coinsurance and out-of-pocket maximums, can sometimes
be confusing. For a quick video that shows how these work, visit http://video.burnhambenefits.com/terms

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