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COVERAGE FEATURES |
Option Plan A (For Actives and all Retirees) |
Option Plan B (For Actives and all Retirees) |
New Option Plan C (For Actives and for Retirees NOT ELIGIBLE for Medicare) Kaiser Permanente Plan |
| CROSS COVERAGE | If an Employee and/or Retiree is covered under the Plan as an Employee and/or Retiree and as a Dependent spouse or Domestic Partner, standard coordination of benefits* provisions apply when the required employee contributions are paid.
The Dual Covered 100% benefit has been eliminated.
*Calendar Year Deductible and Copayments will/may apply.
*Prescription Benefits do not coordinate. |
If an Employee and/or Retiree is covered under the Plan as an Employee and/or Retiree and as a Dependent spouse or Domestic Partner, standard coordination of benefits* provisions apply when the required employee contributions are paid.
The Dual Covered 100% benefit has been eliminated.
*Calendar Year Deductible and Copayments will/may apply.
*Prescription Benefits do not coordinate. |
In Network (at Kaiser facility):
100% coverage*.
At Non-Kaiser facility: Coordination of Benefits provisions apply *Optical excluded.
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| PLAN MAXIMUMS | Unlimited Lifetime Maximum.
$1,500,000 Annual Maximum. |
Unlimited Lifetime Maximum.
$1,500,000 Annual Maximum. |
Unlimited Lifetime Maximum.
No Annual Maximum. |
| DEDUCTIBLE
(Deductible does not apply to routine preventative care) |
In Network:
$250 per individual (plus any Copayments) $500 max per family (plus any Copayments)
Out of Network: $750 per individual (plus any Copayments) $1,500 max per family (plus any Copayments) |
In Network:
$1,000 per individual (plus any Copayments) $2,000 max per family (plus any Copayments)
Out of Network: $3,000 per individual (plus any Copayments) $6,000 max per family (plus any Copayments) |
In Network (at Kaiser facility):
$250 per individual (plus any Copayments) $500 max per family (plus any Copayments)
Deductible does not apply to doctor’s office visits. |
| COST CONTAINMENT PENALTIES | A $250 penalty will be assessed if pre-authorization for non-emergency medical services is not obtained. Any amount that exceeds Usual, Customary, and Reasonable expenses is the Participant’s responsibility and does not apply towards the Out-of-Pocket Maximum. | All covered care must be received from Kaiser Permanente providers, except for the following:
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| OUT-OF-POCKET ANNUAL MAXIMUM [1] (In Network)
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No Covered Person will be required to pay more than $5,000 in any Calendar Year toward the percentage share of expenses which are not paid by the Plan. Once a Covered Person has paid $5,000, Eligible Expenses for the balance of the Calendar Year will be paid at 100%.
No covered family (Employee or retiree and his/her eligible Dependents) will be required to pay more than $10,000 in any Calendar Year toward their percentage share of expenses not paid by the Plan. Once the family has paid $10,000, the remaining Covered Expenses for the balance of the Calendar Year will be paid at 100%. |
No Covered Person will be required to pay more than $6,000 in any Calendar Year toward the percentage share of expenses which are not paid by the Plan. Once a Covered Person has paid $6,000, Eligible Expenses for the balance of the Calendar Year will be paid at 100%.
No covered family (Employee or retiree and his/her eligible Dependents) will be required to pay more than $12,000 in any Calendar Year toward their percentage share of expenses not paid by the Plan. Once the family has paid $12,000, the remaining Covered Expenses for the balance of the Calendar Year will be paid at 100%. |
No Covered Person will be required to pay more than $5,000 in any Calendar Year toward the percentage share of expenses which are not paid by the Plan. Once a Covered Person has paid $5,000, Eligible Expenses for the balance of the Calendar Year will be paid at 100%.
No covered family (Employee or retiree and his/her eligible Dependents) will be required to pay more than $10,000 in any Calendar Year toward their percentage share of expenses not paid by the Plan. Once the family has paid $10,000, the remaining Covered Expenses for the balance of the Calendar Year will be paid at 100%. |
| HOSPITAL SERVICES
Inpatient Hospital Room and Board and Ancillary Services |
In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance after Deductible.
At Non-Kaiser facility: Not covered except for emergencies as defined under Cost Containment Penalties Section. |
| Birthing Center | In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance after Deductible (Covered under Inpatient Hospital, above)
At Non-Kaiser facility: Not covered |
| (No coverage is provided when a Dependent Child is the mother.)
After the birth, the infant and mother are examined and remain in recovery from four (4) to twenty-four (24) hours and then are permitted to return home. Emergency transportation services are also available in case an unforeseen complication arises either with the infant or the mother and an immediate transfer to a Hospital becomes necessary. |
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| Outpatient Services | In Network:
80% of the Anthem Blue Cross Contract Rate after a $100 Copayment.
Out of Network: 60% of the Usual, Customary and Reasonable Charges after a $100 Copayment. |
In Network:
70% of the Anthem Blue Cross Contract Rate after a $100 Copayment.
Out of Network: 50% of the Usual, Customary and Reasonable Charges after a $100 Copayment. |
In Network (at Kaiser facility):
$15 Copayment for specialty, routine, and urgent care. (Plan Deductible Waived)
$0 for routine eye exam, hearing exam, and preventive care. (Plan Deductible Waived)
80% Coinsurance after Deductible for outpatient surgery.
From Non-Kaiser Provider: Not covered unless pre-authorized and referred by a Kaiser Permanente physician.
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COVERAGE FEATURES |
Option Plan A (For Actives and all Retirees) |
Option Plan B (For Actives and all Retirees) |
New Option Plan C (For Actives and for Retirees NOT ELIGIBLE for Medicare) Kaiser Permanente Plan |
| PHYSICIAN SERVICES
Physician Office, Home, or Hospital Visits
All other Physician services and supplies |
In Network: $15 Copayment for each physician office, home, or hospital visit.
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of the Usual, Customary and Reasonable Charges. |
In Network: $25 Copayment for each physician office, home, or hospital visit.
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of the Usual, Customary and Reasonable Charges. |
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| In Network (at Kaiser facility):
$15 Copayment for each physician office visit, home, or hospital visit.
80% Coinsurance after Deductible.
From Non-Kaiser Provider: Not covered unless pre-authorized and referred by a Kaiser Permanente physician. |
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| Non-Authorized Physician Services | In Network:
$250 penalty then 80% of the Anthem Blue Cross Contract Rate.
Out of Network: $250 penalty then 60% of Usual, Customary and Reasonable Charges. |
In Network:
$250 penalty then 70% of the Anthem Blue Cross Contract Rate.
Out of Network: $250 penalty then 50% of Usual, Customary and Reasonable Charges. |
No coverage for care received from a non-Kaiser physician, except for the following:
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| OUTPATIENT LAB & X-RAY | In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
Preventive Care Lab & X-ray: No Copayment, Covered at 100%. (Plan Deductible Waived)
Most Other Lab & X-ray: $10 Copayment after deductible
From Non-Kaiser Provider: Not covered |
| PREVENTIVE HEALTH CARE [2]
(Routine checkups, immunizations, pap smear, etc.)
(Plan Deductible Waived) |
In Network:
No Copayment. 100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges up to a Maximum of $300 per Calendar Year. |
In Network:
No Copayment. 100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges up to a Maximum of $300 per Calendar Year. |
In Network (at Kaiser facility):
No Copayment. Covered at 100%. (Plan Deductible Waived)
From Non-Kaiser provider: Not covered |
| Annual Physical Exam Benefit:
(Plan Deductible Waived) |
In Network:
No Copayment. 100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges up to a Maximum of $300 per Calendar Year.
Routine Annual Physical Examination. This benefit provides coverage for expenses relating to periodic health evaluations for preventive health services to promote healthy lifestyles and to detect unknown diseases or conditions. Examples of types of services covered under this benefit: (a) routine annual physical examinations and laboratory tests, including PSA testing for prostate cancer, when no medical condition exists; (b) routine annual visit to a Dermatologist to determine if skin lesions, moles, etc are cancerous; (c) immunizations.
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In Network:
No Copayment. 100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges up to a Maximum of $300 per Calendar Year.
Routine Annual Physical Examination. This benefit provides coverage for expenses relating to periodic health evaluations for preventive health services to promote healthy lifestyles and to detect unknown diseases or conditions. Examples of types of services covered under this benefit: (a) routine annual physical examinations and laboratory tests, including PSA testing for prostate cancer, when no medical condition exists; (b) routine annual visit to a Dermatologist to determine if skin lesions, moles, etc are cancerous; (c) immunizations. |
In Network (at Kaiser facility):
No Copayment. Covered at 100%. (Plan Deductible Waived)
From Non-Kaiser provider: Not covered |
| WELL BABY CARE [3]
(Plan Deductible Waived) |
In Network:
100% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges.
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In Network:
100% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
No Copayment. Covered at 100%. (Plan Deductible Waived)
From Non-Kaiser provider: Not covered. |
| (During the first five years after birth)
Childhood immunizations and screening that qualify as preventive care services under PPACA are covered at 100% when a Network provider is used. Please see footnote.
Includes Immunizations approved by FDA at intervals recommended by the American Pediatric Association. Excludes immunizations required exclusively for travel.
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(During the first 23 months after birth) | ||
| DURABLE MEDICAL EQUIPMENT |
(Purchase or rental in excess of $2,000 must be preauthorized by Anthem Blue Cross.)
In Network: 80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges.
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(Purchase or rental in excess of $2,000 must be preauthorized by Anthem Blue Cross.)
In Network: 70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges.
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In Network (at Kaiser facility):
80% Coinsurance after Deductible per item.
From non-Kaiser provider: Not covered. |
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PRESCRIPTION DRUGS (For Actives and Retirees [4]) |
Envision Rx Pharmacies |
Envision Rx Pharmacies |
Kaiser Permanente Pharmacies |
| Retail Pharmacy | $10 Copayment Generic
$35 Copayment Brand with no Generic equivalent $35 Copayment plus cost difference for Brand with Generic equivalent [5] |
$10 Copayment Generic
$35 Copayment Brand with no Generic equivalent $35 Copayment plus cost difference for Brand with Generic equivalent 2 |
$10 Copayment Generic
$35 Copayment Brand
No coverage for Prescriptions filled at non-Kaiser pharmacies, except for the following:
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| 1 to 30-day supply at Network Pharmacies.
Up to a 90 day supply at select pharmacy chains for maintenance and non-maintenance drugs. |
Up to 100 day supply | ||
| Mail Order Pharmacy | $10 Copayment Generic
$35 Copayment Brand with no Generic equivalent $35 Copayment plus cost difference for Brand with Generic equivalent 2 |
$10 Copayment Generic
$35 Copayment Brand with no Generic equivalent $35 Copayment plus cost difference for Brand with Generic equivalent 2 |
$20 Copayment Generic
$70 Copayment Brand
No coverage for prescriptions filled at non-Kaiser Mail Order Pharmacy. |
| 1 to 90 days supply for maintenance and non-maintenance drugs.
91 to 180 days supply for maintenance drugs; requires initial 30-day prescription before 91-180 supply will be allowed |
Up to 100 day supply | ||
| Mental Health
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Preauthorization by Avante Health is required for all Mental Health Services
Inpatient Treatment Covered at 100% No Inpatient Deductible
Inpatient, Partial and Day Treatment – 30 units per Calendar Year (inpatient 1 day = 1 unit, residential 1.5 days = 1 unit, partial day 2 days = 1 unit)
Outpatient Treatment 45 visits per Calendar Year $10 Copayment Per Visit |
In Network (at Kaiser facility):
Inpatient Treatment 80% Coinsurance after Deductible
Outpatient Treatment $15 Copayment per visit for Individual outpatient treatment (Plan Deductible Waived)
$10 Copayment per visit for Group outpatient treatment (Plan Deductible Waived)
From non-Kaiser facility: Not covered. |
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| Substance Abuse | Preauthorization by Avante Health is required for all Substance Abuse Services
All levels of Substance Abuse care are covered at 100%
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In Network (at Kaiser facility):
Inpatient Treatment 80% Coinsurance after Deductible
Outpatient Treatment $15 Copayment per visit for Individual outpatient treatment (Plan Deductible Waived)
$10 Copayment per visit for Group outpatient treatment (Plan Deductible Waived)
From non-Kaiser facility: Not covered. |
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| SKILLED NURSING FACILITY | In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance after Deductible (up to 100 days per benefit period)
From non-Kaiser facility: Not covered. |
| HOME HEALTH CARE (only as a less costly alternative to Inpatient hospitalization) | In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
Covered at 100% (Plan Deductible Waived)
From non-Kaiser provider: Not covered. |
| HOSPICE CARE (Plan Deductible Waived)
The Plan covers charges by hospices that are preauthorized. |
In Network:
100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges. |
In Network:
100% of the Anthem Blue Cross Contract Rate.
Out of Network: 100% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
Covered at 100% (Plan Deductible Waived)
From non-Kaiser provider: Not Covered. |
| OCCUPATIONAL AND SPEECH THERAPY
(Requires pre-authorization) |
In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance after a $15 Copayment per visit, after Deductible.
From non-Kaiser provider: Not covered.
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| EMERGENCY, URGENT CARE AND AMBULATORY SERVICES
Emergency Room |
In Network:
80% of the Anthem Blue Cross Contract Rate after a $100 Copayment (Copayment waived if admitted).
Out of Network: 80% of Usual, Customary and Reasonable Charges after a $100 Copayment (Copayment waived if admitted). |
In Network:
70% of the Anthem Blue Cross Contract Rate after a $100 Copayment (Copayment waived if admitted).
Out of Network: 70% of Usual, Customary and Reasonable Charges after a $100 Copayment (Copayment waived if admitted). |
In Network (at Kaiser facility):
80% Coinsurance after Deductible.
From non-Kaiser facility or provider: Not covered except emergencies for as defined under Cost Containment Penalties Section. |
| Urgent Care Facility | In Network:
80% of the Anthem Blue Cross Contract Rate after a $35 Copayment.
Out of Network: 60% of Usual, Customary and Reasonable Charges after a $35 Copayment. |
In Network:
70% of the Anthem Blue Cross Contract Rate after a $35 Copayment.
Out of Network: 50% of Usual, Customary and Reasonable Charges after a $35 Copayment. |
In Network (at Kaiser facility):
80% Coinsurance after a $15 Copayment (Plan Deductible Waived)
From non-Kaiser facility or provider: Not covered. |
| Ambulatory Surgical Center | In Network:
80% of the Anthem Blue Cross Contract Rate after a $100 Copayment.
Out of Network: 60% of Usual, Customary and Reasonable Charges after a $100 Copayment. |
In Network:
70% of the Anthem Blue Cross Contract Rate after a $100 Copayment.
Out of Network: 50% of Usual, Customary and Reasonable Charges after a $100 Copayment. |
In Network (at Kaiser facility):
80% Coinsurance after Deductible
From non-Kaiser facility: Not covered. |
| Ambulance (Air) | 100% with no Copayment. | 100% with no Copayment. | 80% Coinsurance after a $150 Copayment per trip, after Deductible |
| Ambulance (Ground) | 80% after a $100 Copayment. | 70% after a $100 Copayment. | 80% Coinsurance after a $150 Copayment after Deductible |
| OTHER | |||
| Voluntary Sterilization
(Does not include Dependent Children) |
In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance after Deductible.
From a non-Kaiser facility: Not covered. |
| Blood, Blood Plasma, Blood Derivatives and Blood Factors | In Network:
80% of the Anthem Blue Cross Contract Rate.
Out of Network: 60% of Usual, Customary and Reasonable Charges. |
In Network:
70% of the Anthem Blue Cross Contract Rate.
Out of Network: 50% of Usual, Customary and Reasonable Charges. |
In Network (at Kaiser facility):
80% Coinsurance No charge after Deductible.
From a non-Kaiser facility: Not covered. |
| CHIROPRACTIC BENEFITS | You will maintain you current chiropractic benefits through ChiroMetrics as follows:
Chiropractic services by ChiroMetrics Provider: $5 Copayment then 100% of the ChiroMetrics contract rate
Chiropractic services by Non-ChiroMetrics Provider (Outside 100 miles of Fresno ONLY): Referral must be given by a Physician and also Pre-Certified by ChiroMetrics. 70% of Usual, Customary and Reasonable Charges
Chiropractic Diagnostic X-Ray Benefit is limited to a $100 per benefit Calendar Year maximum paid at 100% Usual, Customary and Reasonable Charges, or the ChiroMetrics contract rate, after the Plan’s Deductible has been satisfied.
28 visits maximum per Calendar Year. 10 visits allowed per month and 1 visit allowed per day. Note: For chiropractic treatment exceeding 12 visits per Calendar year, the chiropractor must submit a “12th visit review” and ChiroMetrics must pre-certify additional visits for the remainder of the Calendar Year.
Massage therapy is excluded unless pre-certification is received from ChiroMetrics.
The following protocol will apply for chiropractic treatment for minor children: Treatment For Dependents 15 years of age and under requires Special pre-certification by calling ChiroMetrics at (559) 447-3375. All children fifteen (15) years of age and under must have a written precertification for treatment before any claims will be paid. In the case of an Emergency or where authorization was unable to be obtained on the first visit, then ONLY the first visit will be covered. |
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NOTE: This is only a brief summary of Plans available. Please refer to the Plan Booklet (Plans A and B) and the Kaiser Evidence of Coverage brochure for additional information. There are no changes to the mental health, substance abuse, vision, or dental plans outlined in the Plan Booklet during this Special Option Enrollment.
[1] Deductibles, Copayments and any Plan Penalties do not apply towards Out-of-Pocket Maximum. Out of Network Out-of-Pocket Maximum is two times the In Network amounts shown. Any amount that exceeds Usual, Customary, and Reasonable expenses does not apply towards the Out of Network Out-of-Pocket Maximum.
1 Preventive Services covered under the Patient Protection and Affordable Care Act at Anthem Blue Cross Network Providers and Kaiser Permanent Providers are covered at 100% and not subject to cost sharing effective July 1, 2011.
[3] Well Baby Preventive Services covered under the Patient Protection and Affordable Care Act at Anthem Blue Cross Network Providers and Kaiser Permanent Providers are covered at 100% and not subject to cost sharing effective July 1, 2011.
[4] If you are a Retiree (or a Dependent of a Retiree) who is eligible for Medicare, you will receive the Envision Rx Plus Drug Plan if you are enrolled in Option Plan A or Plan B.
[5] Dispense as Written (DAW prescriptions written by Physicians – cost difference between Brand and Generic waived only if prior authorization received from Envision Rx.)