Plan Benefits Chart
For medical, prescription drug, dental/orthodontics, vision, mental/behavioral health and substance abuse, chiropractic care/acupuncture, and podiatry benefits
View ChartKey Medical Plan Features
Indemnity PPO Medical Plan
See a brief summary of how you and the plan share costs for health care services, as well as your opportunity to earn extra money to pay for eligible health care expenses through a Health Reimbursement Account
Indemnity PPO Medical Plan, Key Features if You Use In-Network Providers
- Preventive Care: The plan pays 100% of the allowed amounts for designated preventive care services. There is no deductible for these services.
- Deductible: You pay $1,000 per person or $2,000 per family per calendar year.
- Coinsurance (applies for most services, e.g., office visits, urgent/emergency care, hospital visits, outpatient procedures): You pay 25% of allowed amounts.
- Annual Medical Out-of-Pocket Maximum (includes deductible and coinsurance): You pay $3,000 per person or $6,000 per family per calendar year.
Health Reimbursement Account (HRA) Funding
Your HRA funding opportunity is based on who’s enrolled in the plan. You receive an automatic “Base HRA Contribution” from the Fund, and you and your enrolled spouse/domestic partner can earn additional contributions to your HRA by completing “Healthy Activities.”
SINGLE COVERAGE
- Automatic Base HRA Contribution from the Fund: $150
- You can EARN $150 for each Healthy Activity completed, up to a maximum of $575 per year (for four activities).
- Total HRA Funding Opportunity (Base + Earned): $725 maximum
EMPLOYEE + CHILDREN COVERAGE
- Automatic Base HRA Contribution from the Fund: $425
- You can EARN $150 for each Healthy Activity completed, up to a maximum of $750 per year (for five activities).
- Total HRA Funding Opportunity (Base + Earned): $1,175 maximum
FAMILY COVERGE (EMPLOYEE + SPOUSE/DOMESTIC PARTNER, WITH OR WITHOUT CHILDREN)
- Automatic Base HRA Contribution from the Fund: $250
- You and your spouse/domestic partner can EARN $150 for each Healthy Activity completed, up to a maximum of $925 per year (for seven activities).
- Total HRA Funding Opportunity (Base + Earned): $1,175 maximum
Kaiser Permanente HMO
- Preventive Care: Kaiser pays 100% for covered services.
- Deductible: None
- You pay set copays at the point of care for most services. For example:
- $25 per visit for primary care physician office visits
- $35 per visit for specialist office visits
- $25 per visit for urgent care
- $150 per procedure for outpatient surgery
- $500 per admission for hospital services
- Annual Medical Out-of-Pocket Maximum: You pay $1,500 per person or $3,000 per family per calendar year.
Anthem Blue Cross HMO
- Preventive Care: Anthem Blue Cross pays 100% for covered services.
- Deductible: None
- There are two networks under the Anthem Blue Cross HMO. Your copay at the point of care depends on the network you choose. For example:
Service Anthem Select HMO Network Anthem CA Care HMO Network Outside the Anthem Select HMO Network Primary Care Physician Office Visits $25 per visit $35 per visit $25 per visit Specialist Office Visits $35 per visit $40 per visit $25 per visit Urgent Care $25 per visit $50 per visit $25 per visit Outpatient Surgery $150 per procedure $200 per visit $100 per procedure Hospital Services $500 per admission $750 per admission $500 per procedure
- Annual Medical Out-of-Pocket Maximum: You pay $1,500 per person or $4,500 per family per calendar year.