Page 10 - SunWest EE Guide 09-19 CA

Medical Plan highlights

Anthem Blue Cross Anthem Blue Cross
Plan Name HMO Priority Select HMO Full Network

Network Name Priority Select HMO California Care HMO

Plan Differences
Employee Premiums $ $$
Health Savings Account
- Employee Funded

Employee Cost Sharing Contribution, Copay, Contribution, Copay,

Network   
- Network Size  
- In-Network Benefits  
- Non-Network Benefits 
Access to Providers Managed by Your PCP Managed by Your PCP
Health Benefits
Lifetime Max Benefit Unlimited Unlimited
Deductible (Cal Year)
- Individual $0 $0
- Per Member $0 $0
- Family $0 $0
Out-of-Pocket Maximum
- Individual $5,000 $5,000
- Per Member N/A N/A
- Family $10,000 $10,000

Coinsurance (Plan Pays) 70% 70%
Office Visit Copay
- Preventive Care No Charge No Charge
- PCP $30 Copay $30 Copay
- Specialist $40 Copay $40 Copay
- Urgent Care $30 Copay $30 Copay
- Virtual Visits $5 Copay $5 Copay

Hospitalization
- Inpatient 30% 30%

- Outpatient Surgery 30% 30%
Emergency Services $200 Copay $200 Copay

Chiropractic $30 Copay $30 Copay
60 Day Limit 60 Day Limit
Acupuncture $30 Copay $30 Copay

10 Employee Benefits