Comparison of Medical/Prescription Plan Offerings |
This is only a summary of the benefits available to you under the Blue Shield PPO Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO's benefits, please refer to the carrier's EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds' website at www.scibew-neca.org. |
Vendor |
Blue Shield PPO |
Kaiser Permanente HMO |
UnitedHealthcare HMO |
|
In Network |
Out-of-Network |
In Network Only |
In Network Only |
Member Customer Service Number |
(855) 599-2650 |
(800) 464-4000 |
(800) 624-8822 |
Website |
www.blueshieldca.com/pponetwork |
www.members.kp.org |
www.myuhc.com |
General Features |
|
|
|
|
Calendar Year Deductible |
$1,000 per individual, $3,000 per Family |
None |
None |
Maximum Benefits |
Unlimited |
Unlimited |
Unlimited |
Annual Co-payment Maximum |
$2,500 per individual, $5,000 per family |
$1,500 per Individual, $3,000 per family |
$2,500 per Individual. $5,000 per family |
Hospital Benefits |
10% co-payment. Hospital Pre-Certification Required. |
30% co-payment additional $200 deductible for non-Blue Shield PPO Hospital or Residential Treatment Center. Hospital Pre-certification Required.2 |
$250 co-payment per admission |
$250 co-payment per admission |
Emergency Services Co-payment waived if admitted |
10% co-payment 1 |
10% co-payment. 2 |
$100 co-payment |
$250 co-payment |
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group |
10% co-payment 1 |
30% co-payment. 2 |
$20 co-payment |
$20 co-payment |
Preexisting Conditions |
All Medically Necessary conditions are covered, provided they are a covered benefit. |
Benefits Available While Hospitalized as an Inpatient |
Alcohol, Drug or Other Substance Abuse Detoxification |
10% co-payment 1 |
30% co-payment 2 |
$250 co-payment per admission |
$250 co-payment per admission |
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). |
10% co-payment 1 |
30% co-payment 2 |
$250 co-payment per admission |
$250 co-payment per admission |
Newborn Care |
10% co-payment 1 |
30% co-payment 2 |
No Charge |
No Charge |
Reconstructive Surgery |
10% co-payment 1 |
30% co-payment 2 |
$250 co-payment per admission |
$250 co-payment |
Rehabilitative Care (including physical, occupational and speech therapy) |
10% co-payment. Must obtain prior approval. 1 |
30% co-payment (Up to $35 max benefit per visit.)2 |
$250 co-payment per hospital admission |
$250 co-payment per admission |
Skilled Nursing Up to 100 Consecutive Days from the first treatment per disability |
10% co-payment. 1 |
30% co-payment. 2 |
No Charge |
$250 co-payment per admission |
Voluntary Termination of Pregnancy (Medical, Medication and surgical) |
No Charge |
No Charge |
No Charge |
No Charge |
Benefits Available on an Outpatient Basis |
Ambulance |
10% co-payment 1 |
10% co-payment 2 |
$100 per trip |
No Charge |
Alcohol, Drug, or Other Substance Abuse Services |
10% co-payment 1 |
30% co-payment 2 |
$20 co-payment per individual visit; $5 co-payment per group visit |
$20 per visit |
Durable Medical Equipment |
10% co-payment. 1 |
30% co-payment. 2 |
No Charge |
No Charge |
Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19) |
10% co-payment. 1 |
30% co-payment. 2 |
No Charge |
No Charge |
Immunizations (For Children Under two (2) years of age, refer to well-baby care) |
No Charge |
30% co-payment 2 |
No Charge |
No Charge |
Laboratory Services (When available through or authorized by PCP) |
10% co-payment. 1 |
30% co-payment. 2 |
No Charge |
No Charge |
Maternity Care, Tests Procedures |
10% co-payment. 1 |
30% co-payment. 2 |
No Charge |
No Charge |
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). |
10% co-payment 1 |
30% co-payment 2 |
$20 per visit |
$25 per visit |
Physician Office Visits and Specialty Office Visits |
10% co-payment 1 |
30% co-payment 2 |
Office Visit $20 co-payment; Specialty Visit $25 co-payment |
Office Visit $20 co-payment; Specialty Visit $25 co-payment |
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility |
10% co-payment 1 |
30% co-payment 2 |
$20 co-payment |
$20 co-payment |
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility |
10% co-payment. 1 |
30% co-payment. 2 |
$250 co-payment |
No Charge |
Preventive Care Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children). |
No Charge 1 |
30% co-payment 2 |
No Charge |
No Charge |
Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children). |
No Charge 1 |
30% co-payment 2 |
No Charge |
No Charge |
Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force). |
No Charge 1 |
30% co-payment 2 |
No Charge |
No Charge |
- Subject to the annual deductible.
- Subject to the annual deductible and balance billing.
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Prescription Drugs Available on an Outpatient Basis: You must use a generic drug substitute whenever it is available. If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, are detailed below: |
Retail Pharmacy; Tier 1 (except Kaiser, Tier 1 represents mostly generic drugs and some brand name drugs) |
$10 up to a 30-day supply |
$10* up to a 30-day supply 1 |
$10 up to a 30-day supply for generic drugs |
$10 up to a 31-day supply |
Retail Pharmacy; Tier 2 (except Kaiser, Tier 2 represents mostly brand drugs and some generic name drugs) |
$20 up to a 30-day supply |
$20* up to a 30-day supply 1 |
$30 up to a 30-day supply for brand name drugs |
$30 up to a 31-day supply |
Mail Order; Tier 1 (except Kaiser, mostly generic drugs and some brand name drugs) |
$20 up to a 90-day supply |
N/A |
$20 up to a 100-day supply for generic drugs |
$20 up to a 90-day supply |
Mail Order; Tier 2 (except Kaiser, mostly brand drugs and some generic name drugs) |
$40 up to a 90-day supply |
N/A |
$60 up to a 100-day supply for brand name drugs |
$60 up to a 90-day supply |
- Blue Shield PPO non-network pharmacy claims -You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited based on the price you paid for the prescription.
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