A Brief Synopsis of the Three Medical Plans

Kaiser, An HMO

In most instances, Kaiser owns its own medical clinics and hospitals, and employs its own doctors. Kaiser may also contract with designated hospitals and Medical Groups. Under the Kaiser Plan, you can choose your own physician, and are encouraged to do so. You must live within the list of Kaiser zip codes to be eligible to enroll in the Kaiser Plan. You can use any Kaiser facility at any time and are not restricted to a particular Medical Group. There are specialist doctors within Kaiser and covered benefits are generally provided to you at no cost or for a fixed copayment.

PacifiCare, An HMO

PacifiCare is a Health Maintenance Organization (HMO). It contracts with doctors who are in private practice or are part of established Medical Groups.

You choose a participating Medical Group and from that Medical Group you must select a primary care physician (PCP). Your PCP will be responsible for all of your healthcare needs, and will refer you to a specialist when necessary. Each medical doctor or group is associated with a particular group of hospitals, which are included in the PacifiCare directory. Generally, covered benefits are provided to you at no cost or for a fixed copayment.

Self-Funded Hospital/Medical Indemnity Plan.

Freedom to Select Doctors. (Includes A Anthem Blue Cross PPO Option)

The Self-Funded Hospital/Medical Indemnity Plan provides you freedom of choice in selecting a doctor. The Board of Trustees have contracted with Anthem Blue Cross of California for the purpose of making the expansive Anthem Blue Cross PPO network available to Employees and their eligible dependents who are covered for benefits under the Indemnity Plan.

Anthem Blue Cross has established a network of "Participating Providers." These providers are called "participating" because they have agreed to participate in the Anthem Blue Cross preferred provider organization program, called PPO for short.

The Anthem Blue Cross PPO is called the Prudent Buyer Plan. Therefore, whenever you see the term "Prudent Buyer" just remember it is the Anthem Blue Cross PPO.

When you use Anthem Blue Cross Participating Prudent Buyer doctors and hospitals, you receive greater benefits than if you were to go to a provider who is not a Anthem Blue Cross Prudent Buyer Participating member. The difference in benefits between using a Participating Anthem Blue Cross Prudent Buyer provider and non-participating provider can be substantial, which affects your out-of-pocket costs.

The PPO providers under contract with the Prudent Buyer Plan agree to provide services at a reduced fee, and the savings are passed along to you in the form of a higher coinsurance, or less out-of-pocket cost to you. When you use a participating Prudent Buyer doctor (In-Network), the coinsurance factor is 90% of a reduced pre-negotiated rate versus 80% when you receive care from a non-participating Prudent Buyer doctor (Out-of-Network).

IMPORTANT: The reimbursement from out-of-network doctors is based on 80% of covered charges for the services you receive. For example, if the Trust determines that a non-PPO doctor charges a higher amount than what are covered charges for the care provided, you may be reimbursed only 60% or 70% for the charge, instead of 80%.

Under the Self-Funded Indemnity Plan, you are responsible for the difference between what the Fund pays and what the doctor charges.