Page 9 - Aspiration Partners Employee Benefits Guide – California

Anthem Blue Cross
Plan Name Classic PPO 750

Prudent Buyer
Network Name PPO Non-Network
Health Benefits

Lifetime Maximum Benefit Unlimited
Calendar Year Deductible
- Individual $750 $2,250
- Family $2,250 $6,750
Out-of-Pocket Maximum
- Individual $5,000 $15,000
- Family $10,000 $30,000
Coinsurance (Plan Pays) 80% 60%
Office Visit Copay
- Preventive Care No Charge Deductible, 40%
- Primary Care Physician $30 Copay Deductible, 40%
- Specialist $50 Copay Deductible, 40%
- Urgent Care $30 Copay Deductible, 40%
Hospitalization
- Inpatient Deductible, 20% Deductible, 40%*
- Outpatient Surgery Deductible, 20% Deductible, 40%*
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 40%
- Complex Deductible, 20% Deductible, 40%*
Emergency Services
Deductible, $150 Copay, 20%
Chiropractic $30 Copay Deductible, 40%

Max 30 Visits/Plan Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0
- Family $0
Retail Pharmacy
- Generic (1a/1b) $5 / $20 50% to $250
- Brand Name Formulary $30 50% to $250
- Brand Non-Formulary $50 50% to $250
- Supply Limit 30 days 30 days
Mail Order Pharmacy
- Generic (1a/1b) $12.50 / $50 Not covered
- Brand Name Formulary $90 Not covered
- Brand Non-Formulary $150 Not covered
- Supply Limit 90 days n/a

*Out-of-Network limits apply