Comparing the Plans - Summary of Benefits
Also See Matrix for Health Plans for Medical Savings Accounts. (Co-Pays and co-insurance amounts listed are the member's responsibility, unless otherwise noted) |
CALIFORNIACARE HMO PLANS |
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| In-Network | CaliforniaCare Plan1 | CaliforniaCare Saver Plan1 |
| Annual Deductible | None | $1,500 per member (applies to certain specific services) |
| Annual Out-of-Pocket Maximum | $2,500 single / $5,000 family | $2,500 single / $5,000 family |
| Lifetime Maximum Benefit | Unlimited | Unlimited |
| Professional Services | $10 office visit co-pay | $10 office visit co-pay |
| Maternity | You pay nothing after $1,000 maternity deductible | You pay nothing after $1,000 maternity deductible; hospital facility charges subject to the $1,500 deductible |
| Outpatient Surgical Facility Fees | 20% co-pay | After $1,500 deductible (for non-emergency services), you pay 20% |
| Preventive Care | $10 co-pay for specific Health Maintenance Care services | $10 co-pay for specific Health Maintenance Care services |
| Preventive Medicine For Women/Well-Baby Care | $10 co-pay for specific Health Maintenance Care services | $10 co-pay for specific Health Maintenance Care services |
| Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Facilities | You pay nothing | You pay nothing |
| Inpatient Hospital Services and Surgical Facilities (Precertification Required) | You pay nothing | After $1,500 deductible (for non-emergency services), you pay nothing |
| Ambulance (Must be medically necessary) | $50 co-pay unless admitted to hospital | $50 co-pay unless admitted to hospital |
| Emergency Care | Inpatient
-- You pay nothing when your care is authorized by your PMG or IPA; you must call your PMG
or IPA within 48 hours of receiving emergency care Outpatient -- $50 emergency room co-pay plus 20% |
Inpatient
-- You pay nothing when your care is authorized by your PMG or IPA; you must call your PMG
or IPA within 48 hours of receiving emergency care Outpatient -- $50 emergency room co-pay plus 20% |
| Home Health Care | You pay nothing for up to 3 (2-hour) visits per day; 100 visits per year | You pay nothing for up to 3 (2-hour) visits per day; 100 visits per year |
| Inpatient Nervous and Mental | You pay 20% of covered inpatient services for substance abuse and detoxification only | You pay 20% of covered inpatient services for substance abuse and detoxification only, after deductible |
| Nervous and Mental Professional Services | Limited
to one visit per day; 20 visits per year $25 co-pay per visit |
Limited
to one visit per day; 20 visits per year $25 co-pay per visit |
| Physical Therapy, Occupational Therapy, Chiropractic Care | Limited to 60 consecutive days following illness or injury; you pay a $10 co-pay per visit | Limited to 60 consecutive days following illness or injury; you pay a $10 co-pay per visit |
| Acupuncture | Not covered | Not covered |
| Outpatient Prescription Drugs - Generic (30-day supply) | $8 co-pay | $8 co-pay |
| Participating Pharmacies (includes oral contraceptives, retail only) - Brand (30-day supply) | $25 co-pay | $25 co-pay |
| Participating Pharmacies - Mail Order (30-day supply) | $10 co-pay (generic) $25 co-pay (brand) | $10 co-pay (generic) $25 co-pay (brand) |
| Contraceptive devices and infertility treatment | Not covered | Not covered |
| MedCall | You have telephone access 24 hours per day, 7 days per week | You have telephone access 24 hours per day, 7 days per week |
CALIFORNIACARE HMO PLANS |
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| Out-of-Network | CaliforniaCare Plan1 | CaliforniaCare Saver Plan1 |
| Annual Deductible | None | $1,500 per member (applies to certain services) |
| Annual Out-of-Pocket Maximum | $2,500 single / $5,000 family | $2,500 single / $5,000 family |
| Out-of-Network Benefit | No benefits, except for certain emergency services | No benefits, except for certain emergency services |
| Inpatient Hospital Services - Contracting Hospital | No benefits, except for certain emergency services | No benefits, except for certain emergency services |
| Inpatient Hospital Services - Non-contracting Hospital | No benefits, except for certain emergency services | No benefits, except for certain emergency services |
| Outpatient Prescription Drugs - Non-Participating Pharmacies | You pay 50% of drug limited fee schedule | You pay 50% of drug limited fee schedule |
CLASSIC CO-PAY PLANS |
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| In-Network | Classic $20 Co-Pay In-Network | Classic $30 Co-Pay In-Network | Classic $40 Co-Pay In-Network |
| Annual Deductible (Per Member) | None | None | None |
| Annual Out-of-Pocket Maximum (Per Member) | $3,000 (2-member family max) | $3,500 (2-member family max) | $4,000 (2-member family max) |
| Lifetime Maximum Benefit | $5,000,000 | $5,000,000 | $5,000,000 |
| Professional Services | $20 office visit co-pay | $30 office visit co-pay | $40 office visit co-pay |
| Maternity | $1,000 co-pay, plus you pay 25% of negotiated fee | $1,000 co-pay, plus you pay 30% of negotiated fee | $1,000 co-pay, plus you pay 35% of negotiated fee |
| Outpatient Surgical Facility Fees | You pay 25% of negotiated fee | You pay 30% of negotiated fee | You pay 35% of negotiated fee |
| Preventive Care | $25 co-pay at Prudent Buyer Check Up Center; $50 and $75 options are available with a greater choice of services | $25 co-pay at Prudent Buyer Check Up Center; $50 and $75 options are available with a greater choice of services | $25 co-pay at Prudent Buyer Check Up Center; $50 and $75 options are available with a greater choice of services |
| Preventive Medicine For Women / Well-Baby Care | $20 co-pay plus 25% of negotiated fee | $30 co-pay plus 30% of negotiated fee | $40 co-pay plus 35% of negotiated fee |
| Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits | You pay 25% of negotiated fee | You pay 30% of negotiated fee | You pay 35% of negotiated fee |
| Inpatient Hospital Services and Surgical Facilities | You pay 25% of negotiated fee at Preferred Participating hospitals; 25% plus $500 admission charge at Participating hospitals | You pay 30% of negotiated fee at Preferred Participating hospitals; 30% plus $500 admission charge at Participating hospitals | You pay 35% of negotiated fee at Preferred Participating hospitals; 35% plus $500 admission charge at Participating hospitals |
| Precertification Required | Additional $250 deductible applies without precertification3 | Additional $250 deductible applies without precertification3 | Additional $250 deductible applies without precertification3 |
| Ambulance (Must be medically necessary) | You pay 25% of negotiated fee | You pay 30% of negotiated fee | You pay 35% of negotiated fee |
| Emergency Care | $30
co-pay applies for each emergency room visit (waived if patient admitted as inpatient) You pay 25% of negotiated fee at Preferred Participating hospitals; 25% plus $250 admission charge at Participating hospitals |
$30
co-pay applies for each emergency room visit (waived if patient admitted as inpatient) You pay 30% of negotiated fee at Preferred Participating hospitals; 30% plus $250 admission charge at Participating hospitals |
$30
co-pay applies for each emergency room visit (waived if patient admitted as inpatient) You pay 35% of negotiated fee at Preferred Participating hospitals; 35% plus $250 admission charge at Participating hospitals |
| Home Health Care | You pay 25% of negotiated rate, up to 90 visits per year | You pay 30% of negotiated rate, up to 90 visits per year | You pay 35% of negotiated rate, up to 90 visits per year |
| Inpatient Nervous and Mental | You pay all covered expense except $175 per day ($5,250 maximum per year) | You pay all covered expense except $175 per day ($5,250 maximum per year) | You pay all covered expense except $175 per day ($5,250 maximum per year) |
| Nervous and Mental Professional Services | Limited
to one visit per day; 20 visits per year You pay any amount over $25 per visit |
Limited
to one visit per day; 20 visits per year You pay any amount over $25 per visit |
Limited
to one visit per day; 20 visits per year You pay any amount over $25 per visit |
| Physical Therapy, Occupational Therapy, Chiropractic Care | Limited
to 12 visits per year unless additional visits approved in advance You pay 25% of negotiated fee |
Limited
to 12 visits per year unless additional visits approved in advance You pay 30% of negotiated fee |
Limited
to 12 visits per year unless additional visits approved in advance You pay 35% of negotiated fee |
| Acupuncture | Limited to 12 visits per year, you pay any amount over $25 per visit | Limited to 12 visits per year, you pay any amount over $25 per visit | Limited to 12 visits per year, you pay any amount over $25 per visit |
| Outpatient Prescription Drugs - Generic (30-day supply) | $10 co-pay | $10 co-pay | $10 co-pay |
| Participating Pharmacies (includes oral contraceptives retail only) - Brand (30-day supply) | $25 co-pay4 | $25 co-pay4 | $25 co-pay4 |
| Participating Pharmacies - Mail Order (60-day supply) | $10 co-pay (generic) $25 co-pay (brand) | $10 co-pay (generic) $25 co-pay (brand) | $10 co-pay (generic) $25 co-pay (brand) |
| Contraceptive devices and infertility treatment | Not covered | Not covered | Not covered |
| MedCall | You have telephone access 24 hours per day, 7 days per week | You have telephone access 24 hours per day, 7 days per week | You have telephone access 24 hours per day, 7 days per week |
CLASSIC CO-PAY PLANS |
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| Out-of-Network | Classic $20 Co-Pay - Out-of-Network | Classic $30 Co-Pay - Out-of-Network | Classic $40 Co-Pay - Out-of-Network |
| Annual Deductible (Per Member) | None | None | None |
| Annual Out-of-Pocket Maximum (Per Member) | Once Blue Cross pays $10,000 in covered expenses, you pay nothing for covered expenses for the rest of the calendar year | Once Blue Cross pays $10,000 in covered expenses, you pay nothing for covered expenses for the rest of the calendar year | Once Blue Cross pays $10,000 in covered expenses, you pay nothing for covered expenses for the rest of the calendar year |
| Out-of-Network Benefit | You pay 50% of Prudent buyer negotiated rate plus any amount over5 | You pay 50% of Prudent buyer negotiated rate plus any amount over5 | You pay 50% of Prudent buyer negotiated rate plus any amount over5 |
| Inpatient Hospital Services - Contracting Hospital | You pay all charges except $380 per year6 | You pay all charges except $380 per year6 | You pay all charges except $380 per year6 |
| Inpatient Hospital Services - Non-contracting Hospital | No benefits, except for certain emergency services | No benefits, except for certain emergency services | No benefits, except for certain emergency services |
| Outpatient Prescription Drugs - Non-Participating Pharmacies | You pay 50% of drug limited fee schedule | You pay 50% of drug limited fee schedule | You pay 50% of drug limited fee schedule |
DEDUCTIBLE PLANS |
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| In-Network | Classic $1,500 Deductible Plan -- In-Network | Classic $2,250 Deductible Plan -- In-Network |
| Annual Deductible (Per Member) | $1,500 (2-member family max) | $2,250 (2-member family max) |
| Annual Out-of-Pocket Maximum (Per Member) | See above (with maternity add $1,000 additional deductible) | |
| Lifetime Maximum Benefit | $5,000,000 | |
| Professional Services | You pay nothing after annual deductible | |
| Maternity | Additional $1,000 deductible applies; you pay nothing | |
| Outpatient Surgical Facility Fees | You pay nothing after annual deductible | |
| Preventive Care | $25 co-pay at Prudent Buyer Check Up Centers, $50 and $75 options are available with a greater choice of services | |
| Preventive Medicine For Women | You pay nothing after annual deductible | |
| Well-Baby Care | You pay 50% of negotiated fee, not subject to annual deductible | |
| Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits | You pay nothing after annual deductible | |
| Inpatient Hospital Services and Surgical Facilities | After annual deductible, you pay nothing at Preferred Participating hospitals; $500 admission charge at Participating hospitals | |
| Precertification Required | Additional $250 deductible applies without precertification3 | |
| Ambulance (Must be medically necessary) | You pay nothing after annual deductible | |
| Emergency Care | $50 deductible applies for each emergency room visit (waived if patient admitted as inpatient), then you pay nothing at Preferred Participating hospitals; $250 admission charge at Participating hospitals | |
| Home Health Care | You pay nothing after annual deductible, up to 60 visits (4 or less hours of treatment) per year, with orders reviewed by physician every 30 days | |
| Inpatient Nervous and Mental | You pay all covered expense except $175 per day ($5,250 maximum benefit per year, after annual deductible) | |
| Nervous and Mental Professional Services | Limited to one visit per day; 20 visits per year After annual deductible, you pay any amount over $25 per visit |
|
| Physical Therapy, Occupational Therapy, Chiropractic Care | Limited to 12 visits per year After annual deductible, you pay nothing |
|
| Acupuncture | Limited to 12 visits per year, after annual deductible, you pay any amount over $25 per visit | |
| Outpatient Prescription Drugs - Generic (30-day supply) | You pay 15% of negotiated rate after separate $100 deductible | |
| Participating Pharmacies (includes oral contraceptives, retail only) - Brand (30-day supply) | You pay 35% of negotiated rate after separate $100 deductible | |
| Participating Pharmacies - Mail Order (60-day supply) | 15% (generic) 35% (brand) after separate $100 deductible | |
| Contraceptive devices and infertility treatment | Not covered | |
| MedCall | You have telephone access 24 hours per day, 7 days per week | |
DEDUCTIBLE PLANS |
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| Out-of-Network | Classic $1,500 Deductible Plan -- Out-of-Network | Classic $2,250 Deductible Plan -- Out-of-Network |
| Annual Deductible (Per Member) | $1,500 (in-network and out-of-network combined) | $2,250 (in-network and out-of-network combined) |
| Annual Out-of-Pocket Maximum (Per Member) | Once Blue Cross pays $10,000 in covered expenses, you pay nothing for cover expenses for the rest of the calendar year. | |
| Out-of-Network Benefit | You pay 50% of Prudent buyer negotiated rate plus any amount over5 | |
| Inpatient Hospital Services - Contracting Hospital | You pay all charges except $380 per day6 | |
| Inpatient Hospital Services - Non-contracting Hospital | No benefits, except for certain emergency services | |
| Outpatient Prescription Drugs - Non-Participating Pharmacies | You pay 40% (generic - formulary) or 50% (brand - formulary) or drug
limited fee schedule after separate $100 deductible You pay 60% (generic or brand - non-formulary) of drug limited fee schedule after separate $100 deductible |
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BASIC PLAN |
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| In-Network | Basic Hospital Plan -- In-Network |
| Annual Deductible (Per Member) | $1,000 (3-member family max) |
| Annual Out-of-Pocket Maximum (Per Member) | Once you pay $3,500 (includes $1,000 deductible & $2,500 in co-insurance for covered service), professional and other services are covered at 100% |
| Lifetime Maximum Benefit | $5,000,000 |
| Professional Services | No benefits until co-insurance maximum is met, then you pay nothing |
| Maternity | Not covered |
| Outpatient Surgical Facility Fees | You pay 20% of negotiated fee, after annual deductible |
| Preventive Care | $25 co-pay at Prudent Buyer Check Up Center, $50 and $75 options available with a greater choice of services |
| Preventive Medicine For Women | You pay 20% of negotiated fee, after annual deductible |
| Well-Baby Care | Not covered |
| Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits | You pay 20% of negotiated fee, after annual deductible |
| Inpatient Hospital Services and Surgical Facilities | After annual deductible, you pay 20% of negotiated fee at Preferred Participating hospitals; 20% plus $250 admission charge at Participating hospitals |
| Precertification Required | Additional $250 deductible applies without precertification3 |
| Ambulance (Must be medically necessary) | You pay any amount over the $750 per trip maximum paid by Blue Cross |
| Emergency Care | $30 deductible applies for each emergency room visit (waived if patient admitted as inpatient), in addition to annual deductible, then you pay 20% of negotiated rate at Preferred Participating hospitals; 20% plus $250 admission charge at Participating hospitals |
| Home Health Care | You pay 20% of negotiated rate, after annual deductible, up to 60 visits (4 or less hours of treatment) per year, with orders reviewed by physician every 30 days |
| Inpatient Nervous and Mental | You pay all covered expense except $175 per day ($5,250 maximum benefit per year, after annual deductible) |
| Nervous and Mental Professional Services | After co-insurance maximum is met, you pay any amount over $25 per visit, limited to one visit per day; 20 visits per year |
| Physical Therapy, Occupational Therapy, Chiropractic Care | Benefit not available |
| Acupuncture | Benefit not available |
| Outpatient Prescription Drugs - Generic (30-day supply) | Not covered |
| Participating Pharmacies (includes oral contraceptives, retail only) - Brand (30-day supply) | Not covered |
| Participating Pharmacies - Mail Order (60-day supply) | Not covered |
| Contraceptive devices and infertility treatment | Not covered |
| MedCall | You have telephone access 24 hours per day, 7 days per week |
BASIC PLAN |
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| Out-of-Network | Basic Plan -- Out-of-Network |
| Annual Deductible (Per Member) | $1,000 (in-network and out-of-network combined) |
| Annual Out-of-Pocket Maximum (Per Member) | Once you pay $3,500 (includes your $1,000 and $2,500 in co-insurance for covered services), you pay 25% of limited fee schedule for professional and most other services |
| Out-of-Network Benefit | You pay 25% of limited fee schedule plus any amount over |
| Inpatient Hospital Services - Contracting Hospital | You pay all charges except $380 per day6 |
| Inpatient Hospital Services - Non-contracting Hospital | No benefits, except for certain emergency services |
| Outpatient Prescription Drugs - Non-Participating Pharmacies | Not covered |
1 All services must be
authorized by your primary care physician. |