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 (CA Only)
Plan Information
Plan Name: Kaiser HMO (CA Only)
Policy Number: 710422
Effective Date: 01/01/2025
Network: Kaiser
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)
$500/up to $1,000 per family
Out-of-Pocket Max (Individual/Family)
$3,000/up to $6,000 per family
Preventive Care
No charge
Primary Care Visit
$30 copay
Specialist Visit
$40 copay
Urgent Care
$30 copay
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay (if authorized)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$60 copay (if authorized)
Plan Documents
Contact Information
Anthem PPO
Plan Information
Plan Name: Anthem PPO
Policy Number: 282875
Effective Date: 01/01/2025
Network: Anthem
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)
$500/up to $1,500 per family
Out-of-Pocket Max (Individual/Family)
$4,250/up to $8,500 per family
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
$30 copay
Emergency Room
$150 copay then 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
1a: $5 copay; 1b: $15 copay
Preferred Brand
Not covered
Non-Preferred Brand
$50 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
1a: $10 copay; 1b: $30 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$150 copay (if authorized)
Out-of-Network
Deductible (Individual/Family)
$1,500/up to $4,500 per family
Out-of-Pocket Max (Individual/Family)
$12,000/up to $24,000 per family
Preventive Care
40% after deductible
Primary Care Visit
40% coinsurance after deductible
Specialist Visit
40% coinsurance after deductible
Urgent Care
40% coinsurance after deductible
Emergency Room
$150 copay then 20% after deductible (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance up to $250
Preferred Brand
50% coinsurance up to $250
Non-Preferred Brand
50% coinsurance up to $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Contact Information
Anthem PPO HSA
Plan Information
Plan Name: Anthem PPO HSA
Policy Number: 282875
Effective Date: 01/01/2025
Network: Anthem
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)
$2,000/up to $5,000 per family
Out-of-Pocket Max (Individual/Family)
$4,250/up to $8,500 per family
Preventive Care
$0
Primary Care Visit
20% coinsurance after deductible
Specialist Visit
20% coinsurance after deductible
Urgent Care
20% coinsurance after deductible
Emergency Room
20% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
1a: $5 copay after deductible; 1b: $15 copay after deductible
Preferred Brand
$40 copay after deductible
Non-Preferred Brand
$60 copay after deductible
Specialty
30% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
1a: $10 copay after deductible; 1b: $30 copay after deductible
Preferred Brand
$100 copay after deductible
Non-Preferred Brand
$150 copay after deductible
Specialty
30% coinsurance, up to $250/prescription
Out-of-Network
Deductible (Individual/Family)
$6,000/up to $12,000 per family
Out-of-Pocket Max (Individual/Family)
$12,750/up to $25,500 per family
Preventive Care
40% coinsurance after deductible
Primary Care Visit
40% coinsurance after deductible
Specialist Visit
40% coinsurance after deductible
Urgent Care
40% coinsurance after deductible
Emergency Room
20% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
40% coinsurance after deductible
Preferred Brand
40% coinsurance after deductible
Non-Preferred Brand
40% coinsurance after deductible
Specialty
40% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered