Page 8 - Aspiration Partners Employee Benefits Guide – California

Limited Network HMO Full Network HMO
No Cost Plan Option Buy-Up Plan Option
Anthem Blue Cross Anthem Blue Cross
Plan Name Select HMO Classic HMO

Network Name Select HMO California Care HMO
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Calendar Year Deductible
- Individual $0 $0
- Family $0 $0
Out-of-Pocket Maximum
- Individual $2,000 $2,000
- Family $4,000 $4,000
Coinsurance (Plan Pays) 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $20 Copay $20 Copay
- Specialist $40 Copay $40 Copay
- Urgent Care $20 Copay $20 Copay

Hospitalization
- Inpatient $250 Copay $250 Copay
- Outpatient Surgery $125 Copay $125 Copay

Lab and X-Ray
- Diagnostic No Charge No Charge
- Complex $100 Copay $100 Copay
Emergency Services $100 Copay $100 Copay
Chiropractic $20 Copay $20 Copay

Limit 60-Day Period Limit 60-Day Period
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Generic (1a/1b) $5 / $15 $5 / $15
- Brand Name Formulary $30 $30
- Brand Non-Formulary $50 $50
- Supply Limit 30 days 30 days
Mail Order Pharmacy
- Generic (1a/1b) $12.50 / $37.50 $12.50 / $37.50
- Brand Name Formulary $90 $90
- Brand Non-Formulary $150 $150
- Supply Limit 90 days 90 days