MEDICAL Y O U R J O U R N E Y T O (CONT’D) HEALTH Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hover over the insurance terms below to learn what they mean. ANTHEM SELECT HMO ELEMENTS CHOICE 1500 ANTHEM CALIFORNIACARE HMO CLASSIC 40/60/750 ADMIT/375 OP (CALIFORNIA EMPLOYEES ONLY) (CALIFORNIA EMPLOYEES ONLY) DEDUCTIBLE Individual: $1,500 Individual: $0 Review Family: $3,000 Family: $0 Plan SBC’s Primary Care: $25 copay Primary Care: $40 copay OFFICE VISITS Specialist: $50 copay Specialist: $60 copay Anthem Select HMO Urgent Care: $25 copay Urgent Care: $40 copay Elements Choice 1500 Inpatient: 30% coinsurance* Inpatient: $750 admission PROCEDURES Outpatient: No charge Outpatient: $40/ Visit; Other outpatient no charge Anthem CaliforniaCare HMO Emergency Room: $250 copay then Emergency Room: $200 copay Classic 40/60/750 ADMIT/375 OP 30% coinsurance Tier 1A: $5 (retail) / $10 (home delivery) Tier 1A: $5 (retail) / $10 (home delivery) Tier 1B: $20 (retail) / $40 (home delivery) Tier 1B: $20 (retail) / $40 (home delivery) PRESCRIPTIONS Tier 2: $50 (retail) / $125 (home delivery) Tier 2: $40 (retail) / $100 (home delivery) Tier 3: $75 (retail) / $188 (home delivery) Tier 3: $60 (retail) / $150 (home delivery) Tier 4: 30% coinsurance up to $250* Tier 4: 30% coinsurance up to $250 OUT-OF-POCKET Individual: $6,400 Individual: $2,500 MAXIMUM Family: $12,800 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 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.