Page 7 - Premier EE Guide 12-17 - CA Final

BENEFITS

MEDICAL INSURANCE

Anthem Blue Cross Anthem Blue Cross
Plan Name Healthy Support HMO PPO

Network Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Calendar Year)
- Individual $0 $500 $1,500
- Family $0 $1,500 $4,500
Co-Insurance (Plan Pays) 100% 80% 60%
Office Visit Copay
- Primary Care Physician $15 Copay $30 Copay Deductible, 40%
- Specialist Office Visit $30 Copay $30 Copay Deductible, 40%
Out-of-Pocket Maximum
- Individual $2,500 $4,000 $12,000
- Family $5,000 $8,000 $24,000

Hospitalization
- Inpatient $250 copay/admission Deductible, 20% Deductible, 40%*
- Outpatient $125 copay/admission Deductible, 20% Deductible, 40%*
Lab and X-Ray
- Diagnostic No Charge Deductible, 20% Deductible, 40%*
- Complex $100 Copay per Test Deductible, 20% Deductible, 40%*
Emergency Services $100 Copay/visit $150 Copay/visit + 20%

Urgent Care $15 Copay $30 Copay Deductible, 40%
Preventive Care No Charge No Charge Deductible, 40%
Chiropractic $15 Copay $30 Copay Deductible, 40%
Limited to 60 Days 30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible $0 $0 $0
Retail Pharmacy
- Tier 1a/1b (typically generic) $5/$15 Copay $5/$15 Copay Copay + 50% up to $250
- Tier 2 (typically preferred/brand) $50 Copay $30 Copay Copay + 50% up to $250
- Tier 3 (typically non-preferred) $65 Copay $50 Copay Copay + 50% up to $250
- Tier 4 (typically specialty drugs) 30% up to $250 max/Rx 30% up to $250 max/Rx Copay + 50% up to $250
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1a/1b (typically generic) $12.50/$37.50 Copay $12.50/$37.50 Copay Not covered
- Tier 2 (typically preferred/brand) $150 Copay $90 Copay Not covered
- Tier 3 (typically non-preferred) $195 Copay $150 Copay Not covered
- Tier 4 (typically specialty drugs) 30% up to $250 max/Rx 30% up to $250 max/Rx Not covered
- Supply Limit 90 Days 90 Days

*Limitations apply. See SBC for details.

7