MEDICAL Y O U R J O U R N E Y T O HEALTH Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hoverovertheinsurancetermsbelowtolearnwhattheymean! Anthem Value DedHMO 2000/30/60/25% Select HMO Anthem Classic HMO 20/40/500 admit/250 OP (California Employees Only) (California Employees Only) DEDUCTIBLE Individual: $2,000 Individual: $0 Family: $4,000 Family: $0 Primary Care: $30 copay Primary Care: $20 copay OFFICE VISITS Specialist: $60 copay Specialist: $40 copay REVIEW Urgent Care: $30 copay Urgent Care: $20 copay PLAN SBC’S Inpatient: *25% Coinsurance Inpatient: *25% Coinsurance PROCEDURES Outpatient: No charge Outpatient: No charge Emergency Room: $200 copay Emergency Room: $125 copay then *25% coinsurance Tier 1A: $5 (retail) / $10 (home delivery) Tier 1A: $5 (retail) / $10 (home delivery) Tier 1B: $20 (retail) / $40 (home delivery) Tier 1B: $15 (retail) / $30 (home delivery) PRESCRIPTIONS Tier 2: $50 (retail) / $125 (home delivery) Tier 2: $30 (retail) / $75 (home delivery) Tier 3: $75 (retail) / $188 (home delivery) Tier 3: $50 (retail) / $125 (home delivery) Tier 4: 30% coinsurance up to $250* Tier 4: 30% coinsurance up to $250 OUT-OF-POCKET Individual: $3,500 Individual: $2,500 MAXIMUM Family: $7,000 Family: $5,000 *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits and Coverage for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.