HMO - caliberbenefits.com Choice Kaiser HMO Benefits.pdf · $3,000/$6,000 $25 Copay $400 Copay ... 25 Plus Health Net* No Deductible ... Max $1,800, Acute detox only Salud HMO y Más6

1

HMOBenefit Summaries 26 plans with office copays from $15 to $40

800.542.4218 www.calchoice.com

CalChoice®HMO152

Anthem Blue Cross*, Health Net*, Kaiser Permanente, Sharp, Western Health Advantage

No Deductible

$15Copay

$15 Copay

$100 Copay

$400Copay-100%

100%

$100 Copay (waived if admitted)

$10Copay

$20Copay

Covered

Covered as any illness

Not Covered

$2,000/$4,000

$15 Copay

$200 Copay

100%

$400 Copay – Max 100 days per year

$50 per trip

Covered

$30 Copay

20 visits per year

Not Covered

$400 Copay - 100% Acute detox only

CalChoiceHMO252

Anthem Blue Cross*

No Deductible

$25Copay

$25 Copay

$100 Copay

$450Copayperday-Max$1,800

100%


$15Copay

$100Ded.-$30Copay

Covered


$25 Copay7

$3,000 / $6,000

$25 Copay

$400 Copay

$25 Copay

100%

$100 per trip

Covered

$25 Copay

No Maximum

$450 Copay per day - Max $1,800

$450 Copay per day – Max $1,800

CalChoiceHMO252

Health Net*

No Deductible

$25Copay

$25 Copay

$100 Copay

$450Copayperday-Max$1,800

100%


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$3,000/$6,000

$25 Copay

$400 Copay

$45 Copay

$450 Copay per day – Max $1,800/100 days per year

$200 per trip

Covered

$40 Copay

20 visits per year

Not Covered

$450 Copay per day – Max $1,800, Acute detox only

CalChoiceHMO252

Kaiser Permanente

No Deductible

$25Copay

$5 Copay

$50 Copay

$400Copay-100%

100%


$10Copay

$25Copay

Covered


Not Covered

$2,500/$5,000

$25 Copay

$300 Copay

100%


$100 per trip

Covered

$25 Copay

No Maximum

$400 Copay - 100%


MedicalBenefits

Participating Health Plans

Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES

Inpatient Physician Fees

Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic

Out-of-Pocket Max Ind/Fam

2nd Surgical Opinion

Outpatient Surgery

Home Health Care

Skilled Nursing Facility

Per Disability

Ambulance

Pre-Existing Conditions

Mental/Nervous Non-Severe 1,4,5

Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees

See footnotes on back page


2

HMOBenefit Summaries

CalChoiceHMO25 Value

Health Net*

No Deductible

$25Copay

$25 Copay

$100 Copay

75%

100%


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$3,000/$6,000

$25 Copay

75%

$45 Copay

75% Max 100 days per year

$200 per trip

Covered

$40 Copay

20 visits per year

Not Covered

75% Acute detox only


Anthem Blue Cross*

$1,000 Sgl. $2,000 Fam. (applies to Max OOP)

$25Copay

$25 Copay

$100 Copay

80%afterdeductible

100%

$150 Copay after deductible (waived if admitted)

$15Copay

$200Ded.-$30Copay

Covered


$25 Copay7

$3,000/$6,000

$25 Copay

80% after deductible

$25 Copay


$100 per trip

Covered

$25 Copay

No Maximum



MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic



Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees

CalChoiceHMO252

Western Health Advantage

No Deductible

$25Copay

$25 Copay

100%

$400Copayperday–Max$1,200

100%


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$2,500/$5,000

$25 Copay

$300 Copay

$30 Copay


$100 per trip

Covered

$25 Copay

No Maximum

$400 Copay per day - Max $1,200


CalChoice®HMO252

Sharp

No Deductible

$25Copay

$25 Copay

100%

$400CopayperdayMax$1,200

100%


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$2,500/$5,000

$25 Copay

$300 Copay

$30 Copay

$400 Copay per day Max $1,200/100 days per year

$100 per trip

Covered

$40 Copay

20 visits per year

Not Covered



3

HMOBenefit Summaries Effective January 1, 2012

ElectOpenAccess

Health Net*

No Deductible

$25CopayHMO$40CopayPPO

$25 Copay

$100 Copay

75%

$25 Copay


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$3,000 Ind/$6,000 Two Party/$7,000 Fam

$25 Copay

75%

100%


100%

Covered

$30 Copay

20 visits per year

75% (30 days per year)


ElectOpenAccess 25Plus

Health Net*

No Deductible


$25 Copay

$100 Copay


$25 Copay


$15Copay

$100Ded.-$30Copay

Covered


Not Covered

$3,000 Ind/$6,000 Two Party/$7,000 Fam

$25 Copay

$400 Copay

100%


100%

Covered

$30 Copay

20 visits per year

$450 Copay per day – Max $1,800, 30 Days per year


SaludHMOyMás6

Health Net

No Deductible

$25Copay

100%

100%


100%


$15Copay

$25Copay

Covered


Not Covered

$2,500/$5,000

$25 Copay

$300 Copay

$30 Copay


$50 per trip

Covered

$40 Copay

20 visits per year

Not Covered


MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic



Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees

CalChoice®HMO302

Anthem Blue Cross*

No Deductible

$30Copay

$30 Copay

$100 Copay


100%


$15Copay

$150Ded.-$30Copay

Covered


$30 Copay7

$3,000/$6,000

$30 Copay

$400 Copay

$30 Copay

100%

$200 per trip

Covered

$30 Copay

No Maximum





4


CalChoiceHMO302

Kaiser Permanente

No Deductible

$30Copay

$10 Copay

$50 Copay

$450Copay-100%

100%

$200 Copay

(waived if admitted)

$15Copay

$30Copay

Covered


Not Covered

$3,000/$6,000

$30 Copay

$400 Copay

100%


$200 per trip

Covered

$30 Copay

No Maximum

$450 Copay - 100%


CalChoiceHMO302


No Deductible

$30Copay

$30 Copay

$50 Copay


100%


$15Copay

$150Ded.-$30Copay

Covered


Not Covered

$3,000/$6,000

$30 Copay

$400 Copay

$45 Copay


$200 per trip

Covered

$30 Copay

No Maximum



CalChoiceHMO302

Sharp

No Deductible

$30Copay

$30 Copay

$50 Copay

$450Copayperday–

Max$1,800

100%

$200 Copay


$15Copay

$150Ded.-$30Copay

Covered


Not Covered

$3,000/$6,000

$30 Copay

$400 Copay

$45 Copay


$200 per trip

Covered

$40 Copay

20 visits per year

Not Covered


CalChoice®HMO302

Health Net*

No Deductible

$30Copay

$25 Copay

$100 Copay

$450Copayperday–

Max$1,800

100%

$200 Copay


$15Copay

$150Ded.-$30Copay

Covered


Not Covered

$3,000/$6,000

$30 Copay

$400 Copay

$45 Copay


$200 per trip

Covered

$40 Copay

20 visits per year

Not Covered


MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic

Out of Pocket Max Ind/Fam


Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees


5

Effective January 1, 2012

CalChoice®HMO30 Value

Health Net*

No Deductible

$30Copay

$30 Copay

$100 Copay

70%

100%

$200 Copay


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500/$7,000

$30 Copay

70%

$45 Copay


$200 per trip

Covered

$40 Copay

20 visits per year

Not Covered


MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic



Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees

CalChoiceHMO402

Anthem Blue Cross*

No Deductible

$40Copay

$40 Copay

$100 Copay

$500Copayperday

100%


$20Copay

$200Ded.-$30Copay

Covered


$40 Copay7

$3,500 / $7,000

$40 Copay

$500 Copay

$40 Copay

100%

$200 per trip

Covered

$40 Copay

No Maximum

$500 Copay per day

$500 Copay per day

CalChoiceHMO402

Kaiser Permanente

No Deductible

$40Copay

$10 Copay

$50 Copay

$500Copayperday

100%


$15Copay

$30Copay

Covered


Not Covered

$3,500/$7,000

$40 Copay

$500 Copay

100%


$200 per trip

Covered

$40 Copay

No Maximum

$500 Copay per day

`

$500 Copay per day –

Acute detox only

CalChoiceHMO402

Health Net*

No Deductible

$40Copay

$25 Copay

$100 Copay

$500Copayperday

100%

$250 Copay


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500/$7,000

$40 Copay

$500 Copay

$50 Copay

$500 Copay per day – Max 100 days per year

$200 per trip

Covered

$50 Copay

20 visits per year

Not Covered

$500 Copay per day – Acute detox only



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MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic



Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees


Anthem Blue Cross*

$1,500 Sgl. $3,000 Fam. (applies to Max OOP)

$40Copay

$40 Copay

$100 Copay

70%afterdeductible

100%


$15Copay

$250Ded.-$30Copay

Covered


$40 Copay7

$4,000/$8,000

$40 Copay


$40 Copay


$200 per trip

Covered

$40 Copay

No Maximum



CalChoiceHMO402


No Deductible

$40Copay

$40 Copay

$50 Copay

$500Copayperday

100%


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500/$7,000

$40 Copay

$500 Copay

$50 Copay


$200 per trip

Covered

$40 Copay

No Maximum

$500 Copay per day


CalChoice®HMO402

Sharp

No Deductible

$40Copay

$40 Copay

$50 Copay

$500Copayperday

100%

$250 Copay


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500/$7,000

$40 Copay

$500 Copay

$50 Copay


$200 per trip

Covered

$50 Copay

20 visits per year

Not Covered



Health Net*

No Deductible

$40Copay

$40 Copay

$100 Copay

60%

100%


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500/$7,000

$40 Copay

60%

$50 Copay


$200 per trip

Covered

$50 Copay

20 visits per year

Not Covered

60%, Acute detox only

7

Effective January 1, 2012


MedicalBenefits


Deductible

DROFFICEVISITS

Lab and X-Ray

MRI, CT, and PET

HOSPITALSERVICES


Emergency Room

RxBENEFITS

Generic

Brand 3

Oral Contraceptives

Maternity

Chiropractic



Outpatient Surgery

Home Health Care


Per Disability

Ambulance



Doctor Fees

Annual Maximum

Hospital Fees

Drug/Alcohol 4,5

Hospital Fees

CalChoice®HMO40 Value


$2,500 Sgl. $5,000 Fam.

$40Copay

100%

$50 Copay

$500Copayperday–afterdeductible(applies to Max OOP )

100%


$20Copay

$250Ded.-$30Copay

Covered


Not Covered

$5,000/$10,000

$40 Copay

$250 Copay

100%


$50 per trip

Covered

$40 Copay

No Maximum

$500 Copay per day – after deductible

$500 Copay per day – after deductible, Acute detox only

ElectOpenAccess 40Plus

Health Net*

No Deductible


$40 Copay

$100 Copay

$500Copayperday

$40 Copay


$20Copay

$200Ded.-$30Copay

Covered


Not Covered

$3,500 Ind/$7,000 Two Party/$8,000 Fam

$40 Copay

$500 Copay

100%


100%

Covered

$30 Copay

20 visits per year

$500 Copay per day – 30 Days per year


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CC5234A.10.11

HMOMedical Benefit Notes

* Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO. Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees.

1 Health plans that provide hospital, medical or surgical coverage must provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and serious emotional disturbances of a child, as specified, under the same terms and conditions applied to other medical conditions. These benefits will include inpatient, partial hospitalization and outpatient services and prescription drugs, if the plan includes drug coverage. The mental health benefits must be applied the same as any other medical benefit including, but not limited to, maximum lifetime benefits, copay and individual and family deductibles. “Severe mental illness” includes: schizophrenia, schizophrenic disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorders, obsessive-compulsive disorder, pervasive development disorder or autism, anorexia and bulimia nervosa.

2 Copayment shall be up to the designated amount, or 50% of provider’s contracted rate, whichever is less.

3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug unless the physician writes “dispense as written” or “do not substitute”. The amount paid does not apply to the member’s brand-name deductible as applicable.

4 For Anthem Blue Cross - Pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a $250 copayment if pre-service review is not obtained; and 2) Outpatient professional services after twelve visits.

5 For complete information as to the mental health/substance abuse benefits and eligibility required under California and federal law, please see mental health/substance abuse benefit description provided by Plan/CHOICE Administrators® Insurance Services. Note: Certain small groups, depending on their size, may be eligible to receive mental health and substance abuse benefits in “parity” with (equivalent to) their medical benefits from Plan.

6 Salud HMO y Más benefits are shown for Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits.

7 In lieu of physical therapy visits. Must be approved by PMG/IPA.

This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable).


PPO† Benefit Summaries

Medical Benefits CalChoice® PPO 750 CalChoice PPO 750 GenRx

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Deductible / Family Maximum $750 per member / $2,250 per family

$750 per member / $2,250 per family



DR. OFFICE VISITS $35 Copay4 (ded. waived) 50% $35 Copay4 (ded. waived) 50%

Annual Physical Exam 100% (ded. waived) Not Covered 100% (ded. waived) Not Covered

Lab And X-Ray 80% 50% 65% 50% (Max $800 Benefit for Advanced Imaging)

(Max $800 Benefit for Advanced Imaging)

HOSPITAL SERVICES $500 Copay - 80% 50% (Up to $650 Per Day)5 $500 Copay - 65% 50% (Up to $650 Per Day)5

Inpatient Physician Fees 80% 50% 65% 50%

Emergency Room $150 $150 $150 $150(waived if admitted)-80% (waived if admitted)-80% (waived if admitted)-65% (waived if admitted)-65%

Rx BENEFITS

Generic Formulary $ 15 Copay $ 15 Copay6 $ 15 Copay8 $ 15 Copay6, 8

Formulary Brand $150 Ded - $30 Copay7 $150 Ded - $30 Copay6, 7 Not Covered Not Covered

Non-Formulary Brand $150 Ded - $50 Copay7 $150 Ded - $50 Copay6, 7 Not Covered Not Covered

Oral Contraceptives Covered Covered Covered Covered

Maternity Covered as any illness Covered as any illness Covered as any illness Covered as any illness

Physical/Occupational Therapy and Chiropractic Care

80% 50% (Up to $25 Per Visit)5 65% 50% (Up to $25 Per Visit)5

Maximum 24 visits per year Maximum 24 visits per year Maximum 24 visits per year Maximum 24 visits per year

Out-of-Pocket Max.– Ind./Fam.1 $4,000/$8,000 $10,000 per member3 $4,500/$9,000 $10,000 per member3

(Includes Ded) (Includes Ded)

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited

Outpatient Surgery $500 Copay - 80% 50% (Up to $380 $500 Copay - 65% 50% (Up to $380Per Admission)5 Per Admission)5

Hospital Pre-Authorization Required Required or Additional $250 Copay Applies

Required Required or Additional $250 Copay Applies

Hospice 100% (ded. waived) 50% 100% (ded. waived) 50%

Skilled Nursing Facility 80% 50% (Up to $150 Per Day)5 65% 50% (Up to $150 Per Day)5

Maximum 100 days per year Maximum 100 days per year Maximum 100 days per year Maximum 100 days per year

Ambulance 80% 50% 65% 50%

Drug & Alcohol Benefits, Mental & Nervous Benefits2

(severe and non-severe)

Outpatient $35 Copay (ded. waived) 50% $35 Copay (ded. waived) 50%

Inpatient $500 Copay - 80% 50% (Up to $650 Per Day)5 $500 Copay - 65% 50% (Up to $650 Per Day)5



PPO Benefit Summaries

Medical Benefits CalChoice® PPO 1000 CalChoice PPO 1000 GenRx


Deductible / Family Maximum $1,000 per member / $3,000 per family

$1,000 per member / $3,000 per family







HOSPITAL SERVICES $1,000 Copay - 70% 50% (Up to $650 Per Day)5 $500 Copay - 55% 50% (Up to $650 Per Day)5



Rx BENEFITS

Generic Formulary $ 15 Copay $ 15 Copay6 $ 15 Copay8 $ 15 Copay6, 8

Formulary Brand $200 Ded - $30 Copay7 $200 Ded - $30 Copay6, 7 Not Covered Not Covered

Non-Formulary Brand $200 Ded - $50 Copay7 $200 Ded - $50 Copay6, 7 Not Covered Not Covered






Out-of-Pocket Max. – Ind./Fam.1 $5,000/$10,000 $10,000 per member3 $5,000/$10,000 $10,000 per member3









Ambulance 70% 50% 55% 50%




Inpatient $1,000 Copay - 70% 50% (Up to $650 Per Day)5 $500 Copay - 55% 50% (Up to $650 Per Day)5


Effective, January 1, 2012

Medical Benefits CalChoice® PPO 3000 CalChoice PPO 4000










HOSPITAL SERVICES $500 Copay - 70% 50% (Up to $650 Per Day)5 $500 Copay - 60% 50% (Up to $650 Per Day)5



Rx BENEFITS

Generic Formulary $ 15 Copay $ 15 Copay6 $ 15 Copay $ 15 Copay6

Formulary Brand $250 Ded - $30 Copay7 $250 Ded - $30 Copay6, 7 $250 Ded - $30 Copay7 $250 Ded - $30 Copay6, 7

Non-Formulary Brand $250 Ded - $50 Copay7 $250 Ded - $50 Copay6, 7 $250 Ded - $50 Copay7 $250 Ded - $50 Copay6, 7






Out-of-Pocket Max. – Ind./Fam.1 $7,000/$14,000 $10,000 per member3 $7,000/$14,000 $10,000 per member3









Ambulance 70% 50% 60% 50%




Inpatient $500 Copay - 70% 50% (Up to $650 Per Day)5 $500 Copay - 60% 50% (Up to $650 Per Day)5


Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider’s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit but there are no benefits for care in non-contracting hospitals, except for medical emergencies. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage.

PPO† Medical Benefit Notes

† These plans are offered by Anthem Blue Cross Life and Health Insurance Company.


Please refer to the CaliforniaChoice® Program brochure for more detailed plan benefit information.

CC5234B.12.11


1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining pre-service review; infertility copay; and non-covered expenses. After a member reaches the out-of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met.

2 Pre-service review is required for the following mental or nervous disorders and substance abuse services; 1) Facility-based treatment or you will be required to pay a $250 copayment if pre-service review is not obtained for non-participating providers; and 2) Outpatient professional services after twelve visits.

3 Once Anthem Blue Cross payments reach $10,000 per insured, the insured pays nothing for covered expenses for the remainder of the year.4 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after

any applicable deductible.5 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or

non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at 50% of Allowable Amounts.

6 Benefits apply to prescriptions filled at participating pharmacies. Please see Health Plan & Formulary Comparison Guide for non-participating pharmacy benefits.

7 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes a “dispense as written” or “do not substitute”, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s pharmacy deductible, if applicable.

8 This prescription drug plan includes coverage for drugs on the GenRx Prescription Drug Formulary only.



CONSUMER DIRECTED PLANS†

Benefit Summaries

Medical Benefits Lumenos HSA 1800 Lumenos HSA 2500


Deductible / Family Maximum $1,800 / $3,6004 (medical and pharmacy combined)

$1,800 / $3,6004 (medical and pharmacy combined)



DR. OFFICE VISITS 80% 50% 80% 50%

Annual Physical Exam 100% (ded. waived) 50% 100% (ded. waived) 50%



HOSPITAL SERVICES 80% 50% (Up to $650 Per Day)5 80% 50% (Up to $650 Per Day)5



Rx BENEFITS

Generic Formulary $ 15 Copay (after deductible) $ 15 Copay (after deductible)6 $ 15 Copay (after deductible) $ 15 Copay (after deductible)6

Formulary Brand2 $30 Copay (after deductible) $30 Copay (after deductible)6 $30 Copay (after deductible) $30 Copay (after deductible)6

Non-Formulary Brand2 $50 Copay (after deductible) $50 Copay (after deductible)6 $50 Copay (after deductible) $50 Copay (after deductible)6






Out-of-Pocket Max.– Ind./Fam.1 $3,000 / $5,500 $3,000 / $5,500 $4,000/$6,000 $4,000/$6,000(Includes Ded) (Includes Ded) (Includes Ded) (Includes Ded)


Outpatient Surgery 80% 50% (Up to $380 80% 50% (Up to $380Per Admission)5 Per Admission)5

Hospital Pre-Authorization Required Required Required Required

Hospice 80% 50% 80% 50%



Ambulance 80% 50% 80% 50%



Outpatient 80% 50% 80% 50%

Inpatient 80% 50% (Up to $650 Per Day)5 80% 50% (Up to $650 Per Day)5

800.542.4218 www.calchoice.comCC5234C.09.11

CONSUMER DIRECTED PLANSBenefit Summaries

Note: Fornon-emergencycare,out-of-networkreimbursementamountisbasedon:anAnthemBlueCrossrateorfeeschedule,aratenegotiatedwiththeprovider,informationfromathirdpartyvendor,orbilledcharges.Membersareresponsibleforthedifferencebetweentheprovider’susualcharges&themaximumallowedamount.Non-participatinghospitalsarecoveredatareducedbenefitbuttherearenobenefitsforcareinnon-contractinghospitals,exceptformedicalemergencies.Formedicalemergencycarerenderedbyanon-participatingproviderornon-contractinghospital,reimbursementisbasedonthereasonableandcustomaryvalue.Membersmayberesponsibleforanyamountinexcessofthereasonableandcustomaryvalue.Plansexcludecoverageforpre-existingconditions(exceptformembersunderage19,achildacquiredthroughlegalguardianshipifthechildisaddedwithin31daysoffinalcourtdecreeororder,achildborntoornewlyadoptedbyanenrolledsubscriberorspouse,orconditionsofpregnancy)forthefirstsixmonthsofcoverageunlessreplacingpriorcreditablecoverage.

† These plans are offered by Anthem Blue Cross Life and Health Insurance Company

1 The following do not apply to the out of pocket maximum: charges paid for acupuncture/acupressure by non-participating providers and non-covered expenses. The insured remains responsible for these amounts even after the out of pocket maximum has been met. In-network and out-of-network out-of-pocket maximums are exclusive of each other; includes calendar year deductible & prescription drug covered expense.

2 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes a “dispense as written” or “do not substitute”, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug.

3 Pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment; and 2) Outpatient professional services after twelve visits.

4 Employees enrolling for single coverage must satisfy the single deductible; for employees enrolling with Dependent coverage, the family deductible must be met before any member receives benefits. In-network and out-of-network deductibles are exclusive of each other; they are applicable to medical care & prescription drug benefits.

5 The coverage amount listed is the maximum allowed charge for non-emergency services received from a Non-Participating Hospital or Non-Participating Provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at 50% of Allowable Amounts.





Healthy Support Summary of Benefits

Medical Benefits CalChoice® PPO 1500 CalChoice® PPO 1750 GenRx








Lab And X-Ray 70% 50% (Max $800 Benefit 55% 50% (Max $800 Benefitfor Advanced Imaging) for Advanced Imaging)

HOSPITAL SERVICES Tier 18 -$1,000 Copay - 70%

Tier 28 -$1,500 Copay - 60%

50% (Up to $650 Per Day)4 Tier 18 -$1,000 Copay - 55%

Tier 28 -$1,500 Copay - 50%

50% (Up to $650 Per Day)4

Inpatient Physician Fees Tier 1 - 70%Tier 2 - 70%

50% Tier 1 - 55%Tier 2 - 55%

50%

Emergency Room Tier 18 - $250 (waived if admitted) - 70%

$250(waived if admitted) - 60%

Tier 18 - $250 (waived if admitted) - 55%

$250 (waived if admitted) - 50%



Rx BENEFITS

Generic Formulary $ 15 Copay $ 15 Copay5 $ 15 Copay7 $ 15 Copay5,7

Formulary Brand $500 Ded - $35 Copay6,9 $500 Ded - $35 Copay5,6,9 Not Covered Not Covered

Non-Formulary Brand Not Covered Not Covered Not Covered Not Covered






Out-of-Pocket Max.– Ind./Fam.1 $5,000/$10,000 $10,000/$20,000 $6,000/$12,000 $12,000/$24,000(Includes Ded) (Includes Ded) (Includes Ded) (Includes Ded)


Outpatient Surgery Tier 18 - $500 Copay - 70%

Tier 28 - $750 Copay - 60%

50% (Up to $380 Per Admission)4

Tier 18 - $500 Copay - 55%Tier 28 - $750 Copay - 50%

50% (Up to $380 Per Admission)4

Hospital Pre-Authorization None OON Only – Required or Additional $250 Copay Applies

None OON Only – Required or Additional $250 Copay Applies


Skilled Nursing Facility 70% Maximum 100 days per year


Maximum 100 days per year55% Maximum 100 days per year


Maximum 100 days per year

Ambulance 70% 50% 55% 50%




Inpatient Tier 1 8 - $1,000 Copay - 70%Tier 28 - $1,500 Copay - 60%


Tier 1 8 - $1,000 Copay - 55%Tier 28 - $1,500 Copay - 50%



Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider’s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage.

Healthy Support Summary of Benefits


CC5234D.5.12


1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining pre-service review; infertility copay; and non-covered expenses. After a member reaches the out-of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met.

2 Pre-service review is required for the following mental or nervous disorders and substance abuse services; 1) Facility-based treatment (non-participating providers) or you will be required to pay a $250 copayment if pre-service review is not obtained; and 2) Outpatient professional services after twelve visits.

3 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible.

4 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at 50% of Allowable Amounts.


6 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes a “dispense as written” or “do not substitute”, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s pharmacy deductible, if applicable.

7 This prescription drug plan includes coverage for drugs on the GenRx Prescription Drug Formulary only.8 The hospital you choose will determine the benefit level payable under the plan. By choosing a Tier 1 Preferred Participating Hospital, you will

receive the highest level of benefits available under this plan. To view the Tier level of the participating hospitals go to www.calchoice.com and click on the Provider/Rx Search link.

9 This prescription drug plan includes coverage for drugs on the Generic Premium Prescription Drug Formulary only.

Documents

HMO - caliberbenefits.com Choice Kaiser HMO Benefits.pdf · $3,000/$6,000 $25 Copay $400 Copay ... 25 Plus Health Net* No Deductible ... Max $1,800, Acute detox only Salud HMO y Más6