Page 6 - California Steel EE Guide 01-19

BENEFITS

Medical Insurance and Prescription Drugs

Delta Health Systems Delta Health Systems Kaiser Permanente
Plan Name (Anthem Blue Cross Network) (Anthem Blue Cross Network)
PPO HDHP PPO HMO
Network Name Prudent Buyer Non-Network Prudent Buyer Non-Network Kaiser
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $500 $1,350 $2,700 $0
- Family $0 $1,500 $2,700 $5,400 $0

Co-Insurance (Plan Pays) 90% 70% 80% 60% 100%
Office Visit Copay
- Preventive Care No Charge Deductible, 50% No Charge Deductible, 40% No Charge
- Primary Care Physician $30 Copay Deductible, 30% Deductible, 20% Deductible, 40% $30 Copay
- Specialist Office Visit $50 Copay Deductible, 30% Deductible, 20% Deductible, 40% $50 Copay
- Urgent Care $30 Copay Deductible, 30% Deductible, 20% Deductible, 40% $30 Copay
Out-of-Pocket Maximum
- Individual $3,000 $5,000 $3,000 $5,000 $1,500
- Family $6,000 $10,000 $6,000 $10,000 $3,000

Hospitalization
- Inpatient $250 Copay, $250 Copay, Deductible, 20% Deductible, 40% $250 Copay
then, 10% Deductible, 30%
- Outpatient 10% Deductible, 30% Deductible, 20% Deductible, 40% $50 Copay

Emergency Services $150 Copay Deductible, 20% $150 Copay
Chiropractic $30 Copay Deductible, 30% Deductible, 20% Deductible, 40% Not Covered
Pharmacy Benefits RxBenefits (Express Scripts) RxBenefits (Express Scripts) Kaiser
Pharmacy Deductible $250 brand name
- Individual deductible when N/A See Health N/A N/A
- Family generic is availa- N/A Deductible N/A N/A
ble unless Dr.
prescribes

Retail Pharmacy
- Generic Formulary $15 Copay Not Covered Deductible, 20% Not Covered $15 Copay
- Brand Name Formulary $35 Copay Not Covered Deductible, 20% Not Covered $35 Copay
- Non-Formulary $50 Copay Not Covered Deductible, 20% Not Covered N/A
- Supply Limit 34 Days N/A 34 Days N/A 30 Days
Mail Order Pharmacy
- Generic Formulary $15 Copay Not Covered Deductible, 20% Not Covered $30 Copay
- Brand Name Formulary $70 Copay Not Covered Deductible, 20% Not Covered $70 Copay
- Non-Formulary $100 Copay Not Covered Deductible, 20% Not Covered N/A
- Supply Limit 90 Days N/A 90 Days N/A 100 Days

Important Note about PPO and HSA PPO Prescription Drugs: If you or a family member are prescribed a maintenance
medication, you will be required to use the applicable mail order plan to secure up to a 90-day supply after no more than 2 refills at
your local pharmacy. This will typically result in substantial savings on your out-of-pocket cost of these drugs.

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