Page 8 - American Business Bank EE Guide 01-19 - C2

Medical Insurance

Kaiser Permanente Blue Shield
HMO HMO

Network Kaiser HMO Access+ HMO
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual None None
- Family None None
Out-of-Pocket Maximum
- Individual $1,500 $2,000
- Family $3,000 $4,000
Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $10 Copay $20 Copay
- Specialist Office Visit $10 Copay $20 Copay / $30 Copay (Self-Referral)
- Urgent Care $10 Copay $20 Copay
- Teladoc N/A $5 Copay
Hospitalization
- Inpatient No Charge $250 Copay

- Outpatient Surgery $10 Copay per Procedure $50 - $200 Copay

Diagnostic Lab and X-Ray
- Advanced Imaging No Charge No Charge

- All Other Lab and X-Ray No Charge No Charge

Emergency Services $100 Copay $150 Copay
Chiropractic $10 Copay Not Covered
30 Visits/Year
Pharmacy Benefits

Pharmacy Deductible None None
Retail Pharmacy
- Generic / Tier 1 $10 Copay $10 Copay
- Brand Name / Tier 2 $25 Copay $25 Copay
- Non-Formulary / Tier 3 $25 Copay $40 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic / Tier 1 $20 Copay $20 Copay
- Brand Name / Tier 2 $50 Copay $50 Copay
- Non-Formulary / Tier 3 $50 Copay $80 Copay
- Supply Limit 100 Days 90 Days

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