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MEDICAL PLANS
PLAN NAME
HMO -Kaiser
HMO - Anthem BCBS
Annual Contribution
Annual Contribution Annual Contribution
PCT contribution - Individual
n/a
n/a
PCT contribution - Family
n/a
n/a
Pro-ration shedule - New Hires
n/a
n/a
Benefits
In-Network
In-Network
In-Network
Out-of-Network# In-Network Out-of-Network#
Individual Deductible
(per calendar year)
None
$1,500
$750
$2,250
Family Deductible
(per calendar year)
None
$1,500 per member
$2,250
$6,750
Coinsurance
Plan pays 100%
Plan pays 75%
Plan pays 80% Plan pays 60% Plan pays 80% Plan pays 60%
Individual Out of Pocket Maximum
(Includes deductible and rx expenses)
$1,500
$3,000
$5,000
$15,000
$5,000
$10,000
Family Out of Pocket Maximum
(Includes deductible and rx expenses)
$3,000
$6,000
$10,000
$30,000
$10,000
$20,000
Lifetime Maximum
Unlimited
Unlimited
Preventive Office Visits
$0;
Plan pays 100%
$0;
Plan pays 100%
$0;
Plan pays 100%
40%*
0%;
Deductible waived
Primary Care Office Visit
$25
$25
Specialist Office Visit
$25
$40
Inpatient Hospital
$250/admission
Outpatient Surgery
$100/occurrence
Emergency Room
$100/occurrence;
waived if admitted
$150/occurrence + 25%*;
waived if admitted
Prescription Drug Plan Provisions
(applies to Retail and Mail Order)
3 Tiers = Generic,
Brand and Specialty
Prescription Drug Deductible
N/A
$250 Individual/$750 Family;
waived for Tier 1a/1b
Preventive Prescriptons
(certain medications as defined by the Plan)
N/A
No charge;
Deductible/Copays Waived
Retail Prescription Drugs
(30-day supply)
Tier 1 - Generic
$15
1a: $5 / 1b: $20
1a: $5 / 1b: $20
$10*
Tier 2 - Preferred Brand
$40
$30
$40*
Tier 3 - Non-Preferred Brand
$75
$50
$60*
Tier 4 - Specialty
30% up to $150
maximum/script
30% up to $250
maximum/script
30% up to $250
maximum/script
30%* up to $250
maximum/script
Mail Order Prescription Drugs
(90-day supply)
Tier 1 - Generic
$30
1a: $12.50 / 1b: $50
1a: $12.50 / 1b: $50
$25*
Tier 2 - Preferred Brand
$120
$90
$120*
Tier 3 - Non-Preferred Brand
$225
$150
$180*
Tier 4 - Specialty
30% up to $150
maximum/script
30% up to $250
maximum/script
30% up to $250
maximum/script
30%* up to $250
maximum/script
n/a
$1,000
n/a
$2,000
PPO - Anthem BCBS
HIA - Anthem BCBS
Annual Contribution
Annual HIA Contribution
PCT
deposit made upon enrollment
n/a
1/12 of HIA for each covered month
$2,000
$4,000
Unlimited
Unlimited
40%*;
Additional limits
$150/occurrence + 20%;
waived if admitted
20%*;
Fund applies
40%*
$30
40%*
20%*;
Fund applies
$30
$60
N/A
25%*
N/A
No charge;
Copays Waived
No charge;
Copays Waived
Typically, Tier 1 = lowest cost generics; Tier 1b = higher cost generics; Tier 2 = Preferred Brand; Tier 3 = Non-
Preferred Brand /Specialty and Tier 4 = Specialty (available only through the Specialty Pharmacy Program)
N/A
40%*
In-network copay
+ 50% of
remaining max
allowed amount
N/A
20%*
40%*;
Additional limits
20%*;
Fund applies