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.
Kaiser HMO (California Employees Only)
Plan Information
Plan Name: Kaiser HMO (California Employees Only)
Policy Number: 95613
Effective Date: 10/01/2023
Provider Network: Kaiser Permanente
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)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Mail-Order RX
(Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$60 copay
Plan Documents
Contact Information
Kaiser HMO
800-464-4000
kp.org
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
In-Network
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,2500/ $2,500 per individual, up to $5,000 per family
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Mail-Order RX
(Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$60 copay
Contact Information
800-464-4000
kp.org
Blue Shield PPO 80/60
Plan Information
Plan Name: Blue Shield PPO 80/60
Policy Number: W0054320
Effective Date: 10/01/2023
Provider Network: Blue Shield of California
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)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$5,250/$10,500
Preventive Care
$0
Primary Care Visit
$25 copay
Specialist Visit
$25 copay
Urgent Care
$25 copay
Emergency Room
$150 copay + 20% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$2,250/$6,750
Out-of-Pocket Max (Individual/Family)
$9,500/$19,000
Preventive Care
Not covered
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 copay + 20% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay + 25% after deductible
Preferred Brand
$30 copay + 25% after deductible
Non-Preferred Brand
$50 copay + 25% after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Blue Shield HDHP & PPO
855-599-2650
blueshieldca.com
anthem.com
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
In-Network
Deductible (Individual/Family)
$750 per individual / up to $2,250 per family
Out-of-Pocket Max (Individual/Family)
$5,250 per individual / up to $10,500 per family
Preventive Care
$0
Primary Care Visit
$25 copay
Specialist Visit
$25 copay
Urgent Care
$25 copay
Emergency Room
$150 copay + 20% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Mail-Order RX
(Up to 30-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$2,250 per individual / up to $6,750 per family
Out-of-Pocket Max (Individual/Family)
$9,500 per individual / up to $19,000 per family
Preventive Care
Not covered
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 copay + 20% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay plus 25% after deductible
Preferred Brand
$30 copay plus 25% after deductible
Non-Preferred Brand
$50 copay plus 25% after deductible
Mail-Order RX
(Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Blue Shield HSA Compatible PPO 2250/3000/4500
Plan Information
Plan Name: Blue Shield HSA Compatible PPO 2250/3000/4500
Policy Number: W0054320
Effective Date: 10/01/2023
Provider Network: Blue Shield of California
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)
$2,250/$4,500
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
$0
Primary Care Visit
20% after deductible
Specialist Visit
20% after deductible
Urgent Care
20% after deductible
Emergency Room
$150 copay + 20% after deductible (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$25 copay after deductible
Non-Preferred Brand
$40 copay after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$80 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$2,250/$4,500
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Not covered
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$150 copay + 20% after deductible (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay + 25% after deductible
Preferred Brand
$25 copay + 25% after deductible
Non-Preferred Brand
$40 copay + 25% after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Blue Shield HDHP & PPO
855-599-2650
blueshieldca.com
anthem.com
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
In-Network
Deductible (Individual/Family)
$2,250 per individual / up to $4,500 per family
Out-of-Pocket Max (Individual/Family)
$3,500 per individual / up to $7,000 per family
Preventive Care
$0
Primary Care Visit
20% after deductible
Specialist Visit
20% after deductible
Urgent Care
20% after deductible
Emergency Room
$150 copay + 20% after deductible (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$25 copay after deductible
Non-Preferred Brand
$40 copay after deductible
Mail-Order RX
(Up to 30-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$80 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$2,250 per individual / up to $4,500 per family
Out-of-Pocket Max (Individual/Family)
$6,000 per individual / up to $12,000 per family
Preventive Care
Not covered
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$150 copay + 20% after deductible (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay plus 25% after deductible
Preferred Brand
$25 copay plus 25% after deductible
Non-Preferred Brand
$40 copay plus 25% after deductible
Mail-Order RX
(Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Blue Shield PPO 90/70
Plan Information
Plan Name: Blue Shield PPO 90/70
Policy Number: W0054320
Effective Date: 10/01/2023
Provider Network: Blue Shield of California
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)
$250/$750
Out-of-Pocket Max (Individual/Family)
$2,750/$5,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$250/$750
Out-of-Pocket Max (Individual/Family)
$10,250/$20,500
Preventive Care
Not covered
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay + 25% after deductible
Preferred Brand
$30 copay + 25% after deductible
Non-Preferred Brand
$50 copay + 25% after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Blue Shield HDHP & PPO
855-599-2650
blueshieldca.com
anthem.com