Page 10 - SunWest EE Guide 09-19 Outside CA

Medical Plan highlights

Anthem Blue Cross Anthem Blue Cross Anthem Blue Cross
Plan Name HRA PPO HSA PPO PPO
BlueCard Non- BlueCard Non- BlueCard Non-
Network Name PPO Network PPO Network PPO Network
Plan Differences
Employee Premiums $ $$ $$$
Health Account After deductible below, 
- Employer Funded* $1,500 / $3,000  
- Employee Funded  

Employee Cost Sharing Contribution, Deductible, Contribution, Deductible, Contribution, Deductible,
Coinsurance Coinsurance Copay, Coinsurance
Network   
- Network Size   
- In-Network Benefits   
- Non-Network Benefits   
Access to Providers Managed by You Managed by You Managed by You
Health Benefits
Lifetime Max Benefit Unlimited Unlimited Unlimited
Deductible (Cal Year) (EE pays*)
- Individual $3,000 $13,500 $2,000 $6,000 $2,500 $2,500
- Per Member $3,000 $13,500 $2,700 $6,000 $2,500 $2,500
- Family $6,000 $27,000 $4,000 $12,000 $5,000 $5,000
Out-of-Pocket Maximum
- Individual $6,350 $19,050 $3,000 $9,000 $6,350 $10,500
- Per Member $6,350 $19,050 $3,000 $9,000 $6,350 $10,500
- Family $12,700 $38,100 $6,000 $18,000 $12,700 $21,000
Coinsurance (Plan Pays) 80% 50% 80% 60% 80% 50%
Office Visit Copay
- Preventive Care No Charge Ded, 50% No Charge Ded, 40% No Charge Ded, 50%
- PCP Ded, 20% Ded, 50% Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Specialist Ded, 20% Ded, 50% Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Urgent Care Ded, 20% Ded, 50% Ded, 20% Ded, 40% $25 Copay Ded, 50%
- Virtual Visits: Ded, 20% Ded, 50% Ded, 20% Ded, 40% $5 Copay Ded, 50%
Hospitalization
- Inpatient Ded, 20% Ded, 50% Ded, 20% Ded, 40% Ded, $100 Ded, 50%
- Outpatient Surgery Ded, 20% Ded, 50% Ded, 20% Ded, 40% Copay, 20%
Ded, 20% Ded, 50%
Emergency Services Ded, 20% Ded, 20% Ded, $100 Copay, 20%
Chiropractic Ded, 20% Ded, 50% Ded, 20% Ded, 40% $25 Copay Ded, 50%
Max 30 Visits/Year Max 30 Visits/Year Max 30 Visits/Year

Acupuncture Ded, 20% Ded, 50% Ded, 20% Ded, 40% $25 Copay Ded, 50%
Max 20 Visits/Year Max 20 Visits/Year Max 20 Visits/Year

*Once you meet the deductible for the HRA in the chart, Sun West will pay for the remaining deductible required for
in-network services, up to the health account amounts shown above.

10 Employee Benefits