HMO & EPO Plan Summaries
Base Plan (CA Only)
Base Plan (Non-CA Only)
Standard Plan (CA Only) Classic HMO California Care
Elements Choice HMO CA Care
Plan Highlights
Anthem EPO
In-network Coverage Only
Annual Calendar Year Deductible Individual / Family Maximum Calendar Year Out-of-Pocket Individual / Family
$1,500 per member
$3,000 / $6,000
None
$6,400 / $12,800
$7,350 / $14,700
$2,500 / $5,000
Professional Services
Primary Care Physician (PCP) Office Visit
$25 copay per visit $50 copay per visit
$25 copay per visit $50 copay per visit
$40 copay per visit $60 copay per visit
Specialist Office Visits Preventative Care Exam
No charge No charge No charge
No charge No charge
No charge No charge No charge
Well-baby Care
Diagnostic Lab and X-Ray
20% after deductible 20% after deductible 20% after deductible
Complex Diagnostics (MRI / CT Scan) Rehab Services (Physical, Occupational & Speech) Office Visit Acupuncture & Chiro via ASH ( 20 combined visits/benefit period) Acupuncture & Chiro via the Medical Group ( 20 visits/benefit period)
$100 copay per visit $25 copay per visit
$100 copay per test $40 copay per visit
$15 copay per visit
$25 copay per visit
$15 copay per visit
$25 copay per visit
$25 copay per visit
$40 copay per visit
Hospital Services
Inpatient Services Outpatient Surgery
30% after deductible 30% after deductible $100 copay per trip
20% after deductible $750 copay per admit
20% after deductible 20% after deductible $150 copay per visit and 20% after deductible
$375 copay per visit $100 copay per trip $125 copay per visit
Ambulance
Emergency Room
$250 copay per visit and 30% after deductible
Urgent care
$25 copay per visit
$25 copay per visit
$40 copay per visit
Maternity Care
Physician Services Hospital Services
$25 copay per visit 30% after deductible
$25 copay per visit
$40 copay per visit
20% after deductible $750 copay per admit
Mental Health/Substance Abuse Services Inpatient
30% after deductible $25 copay per visit
20% after deductible $750 copay per admit
Outpatient Therapy
$25 copay per visit
$40 copay per visit
Recovery Services
Home health care - (100 visits per year)
$25 copay per visit $25 copay per visit 30% after deductible
20% after deductible 20% after deductible 20% after deductible
$40 copay per visit $40 copay per visit
Rehabilitation services
Skilled nursing care - (100 days per benefit period)
No charge
Prescription Drugs (30 day supply) Generic drugs - (Tier 1a / 1b) Preferred brand drugs - (Tier 2)
$5 / $15 copay
$5 copay $20 copay $40 copay $60 copay
$5/ $15 copay
$40 copay $60 copay
$40 copay $60 copay
Non-preferred brand drugs - (Tier 3)
Specialty drugs - (Tier 4)
30% up to $250 copay
30% up to $250 copay
Benefits Guide 2024-25 11
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