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Benefit SummariesSmall Business Private ExchangeFor Groups of 1-100 EmployeesGroups Beginning 7/1/21(Revised 6/8/21)
CONTENTSAbout this Guide.2Platinum HMO.3Platinum EPO.21Gold HMO. 23Gold PPO. 45Gold EPO.51Silver HMO. 55Silver PPO. 69Silver EPO. 73Bronze HMO. 79Bronze PPO. 87Bronze EPO.89Additional Footnotes. 93The benefits listed in this brochure were collected from all plans participating in the CaliforniaChoice Program and are accurate tothe best of our knowledge at the time of print. If the information in this brochure differs from the information in the SBC (Summaryof Benefits and Coverage), EOC (Evidence of Coverage) or COI (Certificate of Insurance), the EOC or COI applies.1calchoice.com
ABOUT THIS GUIDETRUSTED BY CALIFORNIANS FOR 25 YEARS.When we started CaliforniaChoice in 1996, the idea of offering a program that provided small businesses andtheir employees access to multiple health insurance carriers and benefits was truly revolutionary. Today, we’repleased to offer nine health plans and more than 120 PPO, HMO, EPO, and HSA plan design options.GREATER ACCESS TO DOCTORS, SPECIALISTS, AND HOSPITALSCaliforniaChoice offers health plans in all of theAffordable Care Act’s (ACA) four metal tiers: Bronze,Silver, Gold, and Platinum. Each tier offers a differentpercentage of shared health care costs for theemployee, ranging from 10% to 40% (with the healthplan paying the other 90% to 60%), as shown to theright. This can significantly increase the number of plans,doctors, and specialists available to your employees.METAL TIERS:(% Paid by Health Plan / Employee)BRO NZ E60 % 40 %SILV ER70% 30%GO L D80% 20%P L ATINUM90% 10%Please keep in mind that some plans may pay a different percentage of health care costs than what is shown above for each tier; refer to each plan’s summary ofbenefits for specific covered percentage details.1. CHOOSE YOUR METAL TIER(S) Choose Total Choice (four tiers), or choose Triple, Double, or Single ChoiceOffers employees access tohealth plans and benefitsavailable in all four tiers.Offers employees accessto the health plans andbenefits available in threeneighboring tiers.Offers employees accessto the health plans andbenefits available in twoneighboring tiers.Offers employees accessto the health plans andbenefits available in asingle tier. Bronze, Silver, Gold, Platinum Bronze, Silver, Gold Silver, Gold, Platinum Bronze, Silver Silver, Gold Gold, Platinum BronzeSilverGoldPlatinum2. Define Your Monthly ContributionYour broker will share plan premium information with you. Select your preferred plan and whether you wantto pay a Fixed Percentage of costs (select from 50% to 100%) or a Fixed Dollar Amount toward that plan.3. Employees Select Their BenefitsAfter you select your metal tier(s) and define your contribution, each employee is provided with a personalizedworksheet that spells out all options available, and the specific costs involved. Your employees also haveaccess to other tools at calchoice.com that make it easy to determine which plans best meet their needs.On the following pages you’ll find a summary of the benefits offered in each tier level.For more information, please contact your broker or visit calchoice.com.2
Platinum HMOGroups Beginning 7/1/21ServicesHMO AHMO CHMO DParticipating Health PlansAnthem Blue CrossHealth NetHealth NetNetwork NameSelect HMOWholeCareSalud HMO y MasMetal TierPlatinumPlatinumPlatinumCalendar Year Deductible*NoneNoneNoneOut-of-Pocket Max Ind/Fam 2,500 / 5,000 9 2,500 / 5,000 2,500 / 5,000 3Lifetime MaximumUnlimitedUnlimitedUnlimitedDr. Office Visits (PCP) 20 Copay 30 Copay 30 CopaySpecialist Visit (SPC) 40 Copay 50 Copay 50 CopayLaboratory 10 Copay18 30 Copay 30 CopayX-Ray 10 Copay 18 30 Copay 30 CopayMRI, CT and PET (office setting) 100 Copay per test 250 Copay per procedure 250 Copay per procedureVirtual/Telemedicine Office VisitVariable100%100%Hospital Services – In-Patient 300 Copay per day – 3 days max per admit 500 Copay per day – 4 days max 500 Copay per day – 4 days maxIn-Patient Physician Fees100%100%100%Emergency Room(copay waived if admitted) 250 Copay 250 Copay 250 CopayUrgent Care 20 Copay 50 Copay 50 CopayHospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center 250 Copay 200 Copay 500 Copay 200 Copay 2 500 Copay 200 Copay 2Hospital Pre-AuthorizationRequiredRequiredRequired2nd Surgical Opinion 40 Copay 50 Copay 50 CopayAmbulance Services (per trip) 150 Copay 250 Copay 250 CopayLevel 1 10 Copay / Level 2 20 Copay 16Level 1 35 Copay / Level 2 50 Copay 16Level 1 70 Copay / Level 2 85 Copay 16Level 1 70% / Level 2 60% (up to 250 perprescription 14) (prior auth. required) 12, 16 5 Copay 6, 7 30 Copay 6, 7 50 Copay 6, 770% (up to 250 per prescription 14)(prior auth. required) 6, 7 5 Copay 6, 7 30 Copay 6, 7 50 Copay 6, 770% (up to 250 per prescription 14)(prior auth. required) 6, 7Oral Contraceptives100%100%100%Diabetes – Self-InjectableApplicable Rx Copay 16Applicable Rx Copay 6,7Applicable Rx Copay 6, 7Pre-Existing ConditionsCoveredCoveredCoveredMaternity and Newborn CareCovered as any IllnessCovered as any IllnessCovered as any IllnessPreventive/Wellness Services100% 4100% 4100% 4Chronic Disease ManagementCovered as any Illness 50 Copay 50 CopayChemotherapy 40 Copay100%100%Chiropractic (20 visits max peryear) 20 Copay (20 visits max per benefitperiod) 17Not CoveredNot CoveredAcupuncture 20 Copay 10 Copay 1 10 Copay 1Physical, Occupational,Speech Therapy 20 Copay 18 30 Copay 18 30 Copay 18Rehabilitative & HabilitativeServices and Devices 20 Copay 18 30 Copay 18 30 Copay 18Home Health Care(Max 100 visits per year) 40 Copay (Max 100 visits per benefitperiod) 11 30 Copay 30 CopayRx BenefitsGenericFormulary BrandNon-Formulary BrandSpecialty3calchoice.com202115
Platinum HMOGroups Beginning 7/1/21ServicesHMO AHMO CHMO DParticipating Health PlansAnthem Blue CrossHealth NetHealth NetNetwork NameSelect HMOWholeCareSalud HMO y MasMetal TierPlatinumPlatinumPlatinumSkilled Nursing Facility Per Disability(Max 100 days per benefit period) 100 Copay per day – 3 days maxper admit 19 25 Copay per day (no limit) 25 Copay per day (no limit)Hospice (out-patient)100%100%100%Durable Medical Equipment(Covered when medicallynecessary) 100 Copay70%70% 300 Copay per day – 3 days maxper admit 20 Copay 500 Copay per day – 4 days max 5 500 Copay per day – 4 days max 5 30 Copay 5 30 Copay 5 300 Copay per day – 3 days maxper admit 500 Copay per day – 4 days max 500 Copay per day – 4 days maxInfertilityInfertility Evaluation and TreatmentInfertility DrugsIn Vitro Fertilization (IVF)Gamete Intrafallopian Transfer (GIFT)Zygote Intrafallopian Transfer (ZIFT) 20 Copay 13Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredPediatric VisionCarrierNetworkExamContact LensesFramesMaximum Allowance per yearAnthem VisionBlue View Vision100%100% (in lieu of eyeglasses)100%1 per calendar yearEyeMed 10EyeMed100%100%1 pair per calendar yearNoneEyeMed 10EyeMed100%100%1 pair per calendar yearNonePediatric DentalCarrierNetworkDeductibleOut-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)Anthem DentalPrimeNoneCombined with Medical100%100%50%50%50%Dental Benefit Providers 8, 10Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by serviceDental Benefit Providers 8, 10Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by serviceMental HealthIn-PatientOut-Patient (office visit)Drug/Substance AbuseIn-Patient (Detox Only)*1.2.All services are subject to the deductible unless otherwise stated.Must be medically necessary.Cost share varies depending on type of service, see plan specific EOC for cost shares ofother service types.3. Certain services available in Mexico, have a separate out-of-pocket maximum, but out-ofpocket costs for services received in Mexico and California apply toward satisfaction of bothout-of-pocket maximums.4. See plan specific EOC for information on preventive services.5. Benefits are administered by MHN Services, an affiliate behavioral health administrativeservices company which provides behavioral health services.6. The four prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3:Brand non-formulary; Tier 4: Specialty.7. See plan specific EOC for information regarding preventive drugs and women’scontraceptives.8. The pediatric dental benefits are provided by Health Net and administered by Dental BenefitProviders of California, Inc. (DBP). DBP is a California licensed specialized dental plan and isnot affiliated with Health Net. Additional pediatric dental benefits are covered. See the plan’sEOC for details.9. Family Out-of-Pocket Limit: For any given Member, the Out-of-Pocket Limit is met eitherafter he/she meets their individual Out-of-Pocket Limit, or after the entire family Out-ofPocket Limit is met. The family Out-of-Pocket Limit can be met by any combination ofamounts from any Member; however, no one Member may contribute any more thanhis/her individual Out-of-Pocket Limit toward the family Out-of-Pocket Limit.10. Pediatric dental and vision are included on all plans.11. Limited to 100 4-hour visits per benefit period.12. Classified specialty drugs must be obtained through Anthem’s Specialty Pharmacy Programand are subject to the terms of the program.13. Evaluation only.14. Maximum member responsibility.15. Medical emergency only.16. The four prescription drug tiers are: tier 1 typically generic drugs and low-cost preferredbrand name drugs; tier 2 typically non-preferred generic drugs, preferred brand name drugs;tier 3 typically non-preferred brand name drugs; and tier 4 typically drugs that are biologicsor distributed through a specialty pharmacy. Plans use the RxChoice Tiered Network, whichincludes a choice of two levels of copays -- the first copay listed is for Level 1 pharmaciesand the second copay listed is for Level 2.17. Manipulation Therapy only: benefit maximum of 20 visits per benefit period, office andoutpatient visits combined.18. Amount listed is for office visits only, please see plan specific EOC for other settings/servicesand devices cost shares.19. Coverage for inpatient rehabilitation and skilled nursing services combined is limited to 100days per skilled nursing facility benefit period (not per disability).20. Cost share varies depending on place of service, see plan specific EOC for cost shares ofother settings.21. Cost share amount varies based on type of services rendered and plan.4
Platinum HMOGroups Beginning 7/1/21ServicesHMO EHMO FHMO GParticipating Health PlansHealth NetHealth NetHealth NetNetwork NameFullWholeCareSalud HMO y MasMetal TierPlatinumPlatinumPlatinumCalendar Year Deductible*NoneNoneNoneOut-of-Pocket Max Ind/Fam 2,500 / 5,000 3,000 / 6,000 3,000 / 6,000 11Lifetime MaximumUnlimitedUnlimitedUnlimitedDr. Office Visits (PCP) 30 Copay100%100%Specialist Visit (SPC) 50 Copay100%100%Laboratory 30 Copay100%100%X-Ray 30 Copay100%100%MRI, CT and PET (office setting) 250 Copay per procedure 250 Copay per procedure 250 Copay per procedureVirtual/Telemedicine Office Visit100%100%100%Hospital Services – In-Patient 500 Copay per day – 4 days max 500 Copay per day – 4 days max 500 Copay per day – 4 days maxIn-Patient Physician Fees100%100%100%Emergency Room(copay waived if admitted) 250 Copay 250 Copay 250 CopayUrgent Care 50 Copay100%100%Hospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center 500 Copay 200 Copay 1 500 Copay 200 Copay 1 500 Copay 200 Copay 1Hospital Pre-AuthorizationRequiredRequiredRequired2nd Surgical Opinion 50 Copay100%100%Ambulance Services (per trip) 250 Copay 250 Copay 250 Copay 5 Copay 2, 4 30 Copay 2, 4 50 Copay 2, 470% (up to 250 per prescription 5)(prior auth. required) 2, 4100% 2, 4 30 Copay 2, 4 50 Copay 2, 470% (up to 250 per prescription 5)(prior auth. required) 2, 4100% 2, 4 30 Copay 2, 4 50 Copay 2, 470% (up to 250 per prescription 5)(prior auth. required) 2, 4Oral Contraceptives100%100%100%Diabetes – Self-InjectableApplicable Rx Copay 2, 4Applicable Rx Copay 2, 4Applicable Rx Copay 2, 4Pre-Existing ConditionsCoveredCoveredCoveredMaternity and Newborn CareCovered as any IllnessCovered as any IllnessCovered as any IllnessPreventive/Wellness Services100% 6100% 6100% 6Chronic Disease Management 50 Copay100%100%Chemotherapy100%100%100%Chiropractic (20 visits max per year)Not CoveredNot CoveredNot CoveredAcupuncture 10 Copay 10 Copay 10 Copay 3Physical, Occupational,Speech Therapy 30 Copay 7100% 7100% 7Rehabilitative & HabilitativeServices and Devices 30 Copay 7100% 7100% 7Home Health Care(Max 100 visits per year) 30 Copay100%100%Rx BenefitsGenericFormulary BrandNon-Formulary BrandSpecialty5calchoice.com33
Platinum HMOGroups Beginning 7/1/21ServicesHMO EHMO FHMO GParticipating Health PlansHealth NetHealth NetHealth NetNetwork NameFullWholeCareSalud HMO y MasMetal TierPlatinumPlatinumPlatinumSkilled Nursing Facility Per Disability(Max 100 days per benefit period) 25 Copay per day (no limit) 25 Copay per day (no limit) 25 Copay per day (no limit)Hospice (out-patient)100%100%100%Durable Medical Equipment(Covered when medicallynecessary)70%70%70%Mental HealthIn-PatientOut-Patient (office visit) 500 Copay per day – 4 days max 8 30 Copay 8 500 Copay per day – 4 days max 8100% 8 500 Copay per day – 4 days max 8100% 8Drug/Substance AbuseIn-Patient (Detox Only) 500 Copay per day – 4 days max 500 Copay per day – 4 days max 500 Copay per day – 4 days maxInfertilityInfertility Evaluation and TreatmentInfertility DrugsIn Vitro Fertilization (IVF)Gamete Intrafallopian Transfer (GIFT)Zygote Intrafallopian Transfer (ZIFT)Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredPediatric VisionCarrierNetworkExamContact LensesFramesMaximum Allowance per yearEyeMed 9EyeMed100%100%1 pair per calendar yearNoneEyeMed 9EyeMed100%100%1 pair per calendar yearNoneEyeMed 9EyeMed100%100%1 pair per calendar yearNonePediatric DentalCarrierNetworkDeductibleOut-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)Dental Benefit Providers 9, 10Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by serviceDental Benefit Providers 9, 10Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by serviceDental Benefit Providers 9, 10Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by service*1.2.3.4.5.6.7.All services are subject to the deductible unless otherwise stated.Cost share varies depending on type of service, see plan specific EOC for cost shares ofother service types.The four prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3:Brand non-formulary; Tier 4: Specialty.Must be medically necessary.See plan specific EOC for information regarding preventive drugs and women’scontraceptives.Maximum member responsibility.See plan specific EOC for information on preventive services.Amount listed is for office visits only, please see plan specific EOC for other settings/servicesand devices cost shares.8.Benefits are administered by MHN Services, an affiliate behavioral health administrativeservices company which provides behavioral health services.9. Pediatric dental and vision are included on all plans.10. The pediatric dental benefits are provided by Health Net and administered by Dental BenefitProviders of California, Inc. (DBP). DBP is a California licensed specialized dental plan and isnot affiliated with Health Net. Additional pediatric dental benefits are covered. See the plan’sEOC for details.11. Certain services available in Mexico, have a separate out-of-pocket maximum, but out-ofpocket costs for services received in Mexico and California apply toward satisfaction of bothout-of-pocket maximums.6
Platinum HMOGroups Beginning 7/1/21ServicesHMO HHMO AHMO BParticipating Health PlansHealth NetKaiser PermanenteKaiser PermanenteNetwork NameFullFullFullMetal TierPlatinumPlatinumPlatinumCalendar Year Deductible*NoneNoneOut-of-Pocket Max Ind/Fam 3,000 / 6,000 3,000 / 6,000Lifetime MaximumUnlimitedUnlimitedUnlimitedDr. Office Visits (PCP)100% 10 Copay 20 CopaySpecialist Visit (SPC)100% 20 Copay 30 CopayLaboratory100% 20 Copay 20 CopayX-Ray100% 40 Copay 30 CopayMRI, CT and PET (office setting) 250 Copay per procedure 150 Copay per procedure 100 Copay per procedureVirtual/Telemedicine Office Visit100%100%100%Hospital Services – In-Patient 500 Copay per day – 4 days max 500 Copay per admit 250 Copay per day – 5 days maxIn-Patient Physician Fees100%100%100%Emergency Room(copay waived if admitted) 250 Copay 200 Copay 150 CopayUrgent Care100% 10 Copay 20 CopayHospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center 500 Copay 200 Copay 8 300 Copay per procedure 300 Copay per procedure 125 Copay per procedure 125 Copay per procedureHospital Pre-AuthorizationRequiredRequiredRequired2nd Surgical Opinion100% 20 Copay 30 CopayAmbulance Services (per trip) 250 Copay 150 Copay 150 Copay100% 12, 13 30 Copay 12, 13 50 Copay 12, 1370% (up to 250 per prescription 9)(prior auth. required) 12, 13 5 Copay 15 Copay 15 Copay (with physician approval)90% (up to 250 per prescription 9)(with physician approval) 5 Copay 20 Copay 20 Copay (with physician approval)90% (up to 250 per prescription 9)(with physician approval)Oral Contraceptives100%100%100%Diabetes – Self-InjectableApplicable Rx Copay 12, 13 15 Copay 20 CopayPre-Existing ConditionsCoveredCoveredCoveredMaternity and Newborn CareCovered as any IllnessCovered as any IllnessCovered as any IllnessPreventive/Wellness Services100% 5100% 5100% 5Chronic Disease Management100%Covered as any IllnessCovered as any IllnessChemotherapy100%100%90%Chiropractic (20 visits max per year)Not Covered 15 Copay 10Not CoveredAcupuncture 10 Copay 10 Copay 20 CopayRx BenefitsGenericFormulary BrandNon-Formulary BrandSpecialty715None1017 4,500 / 9,000 17Physical, Occupational,Speech Therapy100%14 10 Copay 20 CopayRehabilitative & HabilitativeServices and Devices100% 14 10 Copay 20 CopayHome Health Care(Max 100 visits per year)100%100% 1 20 Copay 1calchoice.com
Platinum HMOGroups Beginning 7/1/21ServicesHMO HHMO AHMO BParticipating Health PlansHealth NetKaiser PermanenteKaiser PermanenteNetwork NameFullFullFullMetal TierPlatinumPlatinumPlatinumSkilled Nursing Facility Per Disability(Max 100 days per benefit period) 25 Copay per day (no limit) 250 Copay per admit 150 Copay per day – 5 days maxHospice (out-patient)100%100%100%Durable Medical Equipment(Covered when medicallynecessary)70%90%90% 6Mental HealthIn-PatientOut-Patient (office visit) 500 Copay per day – 4 days max 16100% 16 500 Copay per admit 10 Copay 250 Copay per day – 5 days max 20 CopayDrug/Substance AbuseIn-Patient (Detox Only) 500 Copay per day – 4 days max 500 Copay per admit 250 Copay per day – 5 days maxInfertilityInfertility Evaluation and TreatmentInfertility DrugsIn Vitro Fertilization (IVF)Gamete Intrafallopian Transfer (GIFT)Zygote Intrafallopian Transfer (ZIFT)Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredPediatric VisionCarrierNetworkExamContact LensesFramesMaximum Allowance per yearEyeMed 7EyeMed100%100%1 pair per calendar yearNoneKaiser PermanenteKaiser Permanente100%1 pair per calendar year 111 pair per calendar year 11NoneKaiser PermanenteKaiser Permanente100%1 pair per calendar year 111 pair per calendar year 11NonePediatric DentalCarrierNetworkDeductibleOut-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)Dental Benefit Providers 4, 7Dental Benefit ProvidersNoneCombined with Medical100%100%Copay varies by serviceCopay varies by serviceCopay varies by serviceDelta DentalDeltaCare USANone 350 / 700100%100% 40 Copay 2 365 Copay 3 350 CopayDelta DentalDeltaCare USANone 350 / 700100%100% 40 Copay 2 365 Copay 3 350 Copay*1.2.3.4.5.6.7.All services are subject to the deductible unless otherwise stated.Home Health Care visit part-time/intermittent coverage (2 hour(s) maximum per visit(s), 3visit(s) maximum per day(s), 100 visit(s) maximum per calendar year).DHMO Basic Services copayments vary by procedure within this category. Using astatistically significant set of claims data, the plan’s average copay charged for procedures inthis category cannot exceed the stated amount.DHMO Major Services copayments vary by procedure within this category. Using astatistically significant set of claims data, the plan’s average copay charged for procedures inthis category cannot exceed the stated amount.The pediatric dental benefits are provided by Health Net and administered by Dental BenefitProviders of California, Inc. (DBP). DBP is a California licensed specialized dental plan and isnot affiliated with Health Net. Additional pediatric dental benefits are covered. See the plan’sEOC for details.See plan specific EOC for information on preventive services.Certain prosthetics, orthotics and devices may be available at no cost (after deductible,if deductible applies). Please refer to the Evidence of Coverage for more information onDurable Medical Equipment (DME), prosthetics, orthotics and devices. Most DME for homeuse, prosthetics, orthotics and devices are not covered.Pediatric dental and vision are included on all plans.8.9.10.11.12.13.14.15.16.17.6Cost share varies depending on type of service, see plan specific EOC for cost shares ofother service types.Maximum member responsibility.20 visits max per year combined for Chiropractic and Acupuncture.1 pair of glasses or 1 pair of contact lenses per accumulation period.The four prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3:Brand non-formulary; Tier 4: Specialty.See plan specific EOC for information regarding preventive drugs and women’scontraceptives.Amount listed is for office visits only, please see plan specific EOC for other settings/servicesand devices cost shares.Must be medically necessary.Benefits are administered by MHN Services, an affiliate behavioral health administrativeservices company which provides behavioral health services.Under a family contract, an insured can satisfy their individual out-of-pocket maximum;however, an insured may not contribute an amount greater than the individual maximumcopayment limit toward the family maximum.8
Platinum HMOGroups Beginning 7/1/219ServicesHMO AHMO BParticipating Health PlansSharpSharpNetwork NamePremierPerformanceMetal TierPlatinumPlatinumCalendar Year Deductible*NoneOut-of-Pocket Max Ind/Fam 3,500 / 7,000Lifetime MaximumUnlimitedUnlimitedDr. Office Visits (PCP) 15 Copay 15 CopaySpecialist Visit (SPC) 20 Copay 30 CopayLaboratory100%100%X-Ray100%100%MRI, CT and PET (office setting) 150 Copay per procedure 100 Copay per procedureVirtual/Telemedicine Office VisitCovered as any IllnessCovered as any IllnessHospital Services – In-Patient 400 Copay85%In-Patient Physician Fees100%85%Emergency Room(copay waived if admitted) 150 Copay85%Urgent Care 20 Copay 30 CopayHospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center80%80%85%85%Hospital Pre-AuthorizationRequiredRequired2nd Surgical Opinion 20 Copay 30 CopayAmbulance Services (per trip) 150 Copay85%Rx BenefitsGenericFormulary BrandNon-Formulary BrandSpecialty 10 Copay 25 Copay 50 CopayApplicable Rx Copay 10 Copay 25 Copay 50 CopayApplicable Rx CopayOral Contraceptives100% (if in formulary)100% (if in formulary)Diabetes – Self-InjectableApplicable Rx CopayApplicable Rx CopayPre-Existing ConditionsCoveredCoveredMaternity and Newborn Care 400 CopayPreventive/Wellness Services100% 4Chronic Disease Management 20 Copay 30 CopayChemotherapyVariableVariable 6Chiropractic (20 visits max per year)Not CoveredNot CoveredAcupuncture 15 Copay 15 CopayPhysical, Occupational,Speech Therapy 15 Copay 15 CopayRehabilitative & HabilitativeServices and Devices 15 Copay 15 CopayHome Health Care(Max 100 visits per year) 15 Copay 15 Copaycalchoice.comNone73 3,000 / 6,000 385% 7100% 46
Platinum HMOGroups Beginning 7/1/21ServicesHMO AHMO BParticipating Health PlansSharpSharpNetwork NamePremierPerformanceMetal TierPlatinumPlatinumSkilled Nursing Facility Per Disability(Max 100 days per benefit period) 200 Copay85%Hospice (out-patient)100%100%Durable Medical Equipment(Covered when medicallynecessary)50%50%Mental HealthIn-PatientOut-Patient (office visit) 400 Copay 15 Copay85% 15 CopayDrug/Substance AbuseIn-Patient (Detox Only) 400 Copay85%InfertilityInfertility Evaluation and TreatmentInfertility DrugsIn Vitro Fertilization (IVF)Gamete Intrafallopian Transfer (GIFT)Zygote Intrafallopian Transfer (ZIFT)Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot CoveredMaximum Allowance per yearVSPVSP Advantage Network100%1 pair in lieu of eyeglasses100% (Pediatric Exchangecollection only)NoneVSPVSP Advantage Network100%1 pair in lieu of eyeglasses100% (Pediatric Exchangecollection only)NonePediatric DentalCarrierNetworkDeductibleOut-of-Pocket MaximumOffice VisitDiagnostic & Preventative (D&P)Basic ServicesMajor Services (no waiting period)Orthodontics (medically necessary)Delta Dental of CaliforniaDelta Dental DeltaCare USANoneCombined with Medical100% 5100% 8 25 Copay 1 300 Copay 2 1,000 Copay 9Delta Dental of CaliforniaDelta Dental DeltaCare USANoneCombined with Medical100% 5100% 8 25 Copay 1 300 Copay 2 1,000 Copay 9Pediatric VisionCarrierNetworkExamContact LensesFrames*1.2.3.4.5.All services are subject to the deductible unless otherwise stated.Refers to procedure code D2140Refers to procedure code D3330Copayments for supplemental benefits (Assisted ReproductiveTechnologies, Chiropractic Services, Adult Vision, etc.) do not apply tothe annual out-of-pocket maximum.See plan specific EOC for information on preventive services.Refers to procedure code D09996.7.8.9.Copay/Coinsurance waived if seen by nurse or in an out-patient setting.Amount listed for In-Patient Services only.Refers to procedure codes D0120 and D1120/D1110Refers to procedure code D8080/D809010
Platinum HMOGroups Beginning 7/1/2111ServicesHMO CHMO AHMO BParticipating Health PlansSharpSutter Health PlusSutter Health PlusNetwork NamePremierSutter Health PlusSutter Health PlusMetal TierPlatinumPlatinumPlatinumCalendar Year Deductible*NoneOut-of-Pocket Max Ind/Fam 4,000 / 8,000Lifetime MaximumUnlimitedUnlimitedUnlimitedDr. Office Visits (PCP) 10 Copay 20 Copay 7 25 Copay 7Specialist Visit (SPC) 20 Copay 30 Copay 40 CopayLaboratory 10 Copay 20 Copay 25 CopayX-Ray 40 Copay 30 Copay per procedure 25 Copay per procedureMRI, CT and PET (office setting) 150 Copay per procedure 100 Copay per procedure 150 Copay per procedureVirtual/Telemedicine Office VisitCovered as any IllnessVariableVariable 18Hospital Services – In-Patient 350 Copay per day – 5 days max 250 Copay per day – 5 days maxper admit 250 Copay per day – 5 days maxper admitIn-Patient Physician Fees100%100%100%Emergency Room(copay waived if admitted) 200 Copay 150 Copay 100 CopayUrgent Care 20 Copay 20 Copay 25 CopayHospital Services – Out-PatientSurgical FacilityAmbulatory Surgery Center80%80% 100 Copay 100 Copay90%90%Hospital Pre-AuthorizationRequiredRequiredRequired2nd Surgical Opinion 20 Copay 30 Copay 40 CopayAmbulance Services (per trip) 200 Copay 150 Copay 100 CopayRx BenefitsGenericFormulary BrandNon-Formulary BrandSpecialty 10 Copay 25 Copay 50 CopayApplicable Rx Copay 5 Copay 2, 3 20 Copay 2, 3 30 Copay 2, 390% (up to 250 per prescription 8) 2, 3 5 Copay 2, 3 15 Copay 2, 3 30 Copay 2, 390% (up to 250 per prescription 8) 2, 3Oral Contraceptives100% (if in formulary)100%100%Diabetes – Self-InjectableApplicable Rx CopayApplicable Rx CopayPre-Existing ConditionsCoveredMaternity and Newborn Care 350 Copay per day – 5 days maxPreventive/Wellness Services100%Chronic Disease Management 20 CopayCovered as any IllnessCovered as any IllnessChemotherapyVariable90%90%Chiropractic (20 visits max per year)Not CoveredNot CoveredNot CoveredAcupuncture 10 Copay 20 Copay 25 CopayPhysical, Occupational,Speech Therapy 10 Copay 20 Copay 25 CopayRehabilitative & HabilitativeServices and Devices 10 Copay 20 Copay 25 CopayHome Health Care(Max 100 visits per year) 10 Copay 20 Copay 25 Copaycalchoice.comNone410None 4,500 / 9,0001115 3,500 / 7,000 11182, 3Applicable Rx Copay 2, 3CoveredCoveredCovered as any IllnessCovered as any Illness100%100% 44
Platinum HMOGroups Beginning 7/1/21ServicesHMO CHMO AHMO BParticipating Health PlansSharpSutter He
Services HMO A HMO C HMO D Participating Health Plans Anthem Blue Cross Health Net Health Net Network Name Select HMO WholeCare Salud HMO y Mas Metal Tier Platinum Platinum Platinum Calendar Year Deductible* None None None Out-of-Pocket Max Ind/Fam 2,500 / 5,000 9 2,500 / 5,000
