Behavior Frontiers offers five choices of medical insurance plans, two HMO plans, two PPO plans, and one High Deductible Health Plan (HDHP). Each of our medical insurance plans offer different levels of deductibles, copayments, and out-of-pocket maximums. MEDICAL
Anthem HMO Plan If you elect coverage in either of the HMO plans you are required to choose a Primary Care Physician (PCP) who is part of the Anthem network as your personal doctor. Each family member covered through your plan can choose his or her own PCP and can change them at any time. All care must be provided or authorized by the PCP. To search the provider list online, visit
www.anthem.com/ca .
Value HMO Plan (CA Only)
Classic HMO Plan (CA Only)
California Care HMO Network
Select HMO Network
Calendar Year Deductible
None
None
$3,500 single $7,000 family
$2,500 single $5,000 family
Calendar Year Out-of-Pocket Maximum
Physician Office Visit
$35 copay
$30 copay
Specialist Office Visit
$55 copay
$50 copay
LiveHealth Online
No charge
No charge
Preventive Care
No charge
No charge
Urgent Care
$35 copay
$30 copay
Diagnostic X-Ray/Lab
No charge
No charge
Outpatient Surgery
$375 copay
$250 per visit
Inpatient Hospital
$750 per day, up to 3 days
$500 per admit
Emergency Room (Waived if Admitted) Pharmacy Deductible Generic (Tier 1a/1b) Preferred (Tier 2) Non-Preferred (Tier 3) Specialty (Tier 4)
$150 copay
$125 copay
$150 individual / $450 family $5/$20
None $5/$15
$40 (after deductible) $60 (after deductible) 30% up to $250 max (after deductible)
$30 $50 30% up to $250 max
Copays and coinsurance percentages shown in the above plan descriptions represent the amount paid by the member. 1. Members are responsible for all charges above Anthem’s allowable amounts when using non -network providers. 2.Additional $500 copay required if you do not receive preauthorization from Anthem for non-emergency visit
4 | Behavior Frontiers Benefits Guide
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