Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Anthem Classic PPO
Plan Information
Plan Name: Anthem Classic PPO
Policy Number: L09445
Effective Date: 01/01/2025
Provider Network: Anthem Blue Cross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$4,250/$8,500
Preventive Care
$0
Primary Care Visit
$30
Specialist Visit
$50
Urgent Care
$30
Emergency Room
$150 + 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5 – $20
Preferred Brand
$40
Non-Preferred Brand
$60
Specialty
30% up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10–$30
Preferred Brand
$75
Non-Preferred Brand
$125
Specialty
30% up to $250 per prescription
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$12,750/$25,500
Preventive Care
40% after deductible
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 + 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance up to $250 per prescription
Preferred Brand
50% coinsurance up to $250 per prescription
Non-Preferred Brand
50% coinsurance up to $250 per prescription
Specialty
50% coinsurance up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Anthem HSA PPO
Plan Information
Plan Name: Anthem HSA PPO
Policy Number: L09445
Effective Date: 01/01/2025
Provider Network: Anthem Blue Cross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,650/$4,100
Out-of-Pocket Max (Individual/Family)
$4,250/$8,500
Preventive Care
$0
Primary Care Visit
10%*
Specialist Visit
10%*
Urgent Care
10%*
Emergency Room
10%*
Retail Rx (Up to 30-Day Supply)
Generic
$5–$20*
Preferred Brand
$40*
Non-Preferred Brand
$60*
Specialty
30% up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10–$30*
Preferred Brand
$100*
Non-Preferred Brand
$150*
Specialty
30% up to $250 per prescription*
*After deductible
Out-of-Network
Deductible (Individual/Family)
$4,950/$9,900
Out-of-Pocket Max (Individual/Family)
$12,750/$25,500
Preventive Care
30%*
Primary Care Visit
30%*
Specialist Visit
30%*
Urgent Care
30%*
Emergency Room
10%*
Retail Rx (Up to 30-Day Supply)
Generic
30% up to $250 per prescription*
Preferred Brand
30% up to $250 per prescription*
Non-Preferred Brand
30% up to $250 per prescription*
Specialty
30% up to $250 per prescription*
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Anthem Classic HMO – CA Employees Only
Plan Information
Plan Name: Anthem Classic HMO – CA Employees Only
Policy Number: L09445
Effective Date: 01/01/2025
Provider Network: Anthem Blue Cross
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$20
Specialist Visit
$40
Urgent Care
$20
Emergency Room
$200 (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5–$20
Preferred Brand
$40
Non-Preferred Brand
$60
Specialty
30% up to $250 per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10–$30
Preferred Brand
$75
Non-Preferred Brand
$125
Specialty
30% up to $250 per prescription