Comparison of Medical Plan Offerings |
This is only a summary of the benefits available to you under the Anthem Blue Cross 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 |
Anthem Blue Cross PPO |
Kaiser HMO |
UnitedHealthcare |
|
In Network |
Out-of-Network |
In Network Only |
In Network Only |
Member Customer Service Number |
(800) 543-3037 |
(800) 464-4000 |
(800) 624-8822 |
Website |
www.bluecrossca.com |
www.members.kp.org |
www.uhcwest.com |
General Features |
|
|
|
|
Calendar Year Deductible |
$200 per individual, $600 per Family |
None |
None |
Maximum Benefits |
Unlimited |
Unlimited |
Unlimited |
Annual Co-payment Maximum |
$1,000 per individual, $2,000 per family |
$1500 per Individual, $3,000 per family |
$1000 per Individual. $3,000 per family |
Hospital Benefits |
10% co-payment. Hospital Pre-Certification Required. |
20% co-payment. Additional $200 deductible for non-Anthem Blue Cross PPO Hospital or Residential Treatment Center and $500 no-preauthorization penalty (waived for emergency services) Hospital Precertification Required. 2 |
No Charge |
No Charge |
Emergency Services |
10% co-payment 1 |
10% co-payment. 2 |
$5 co-payment. Co-payment waived if admitted. |
$50 co-payment. Co-payment waived if admitted. |
Preexisting Conditions |
Not Applicable. All 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 |
20% 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 |
20% co-payment 2 |
No Charge |
No Charge |
Newborn Care |
10% co-payment 1 |
20% co-payment 2 |
No Charge |
No Charge |
Physician Care |
10% co-payment 1 |
20% co-payment 2 |
No Charge |
No Charge |
Reconstructive Surgery |
10% co-payment 1 |
20% co-payment 2 |
No Charge |
No Charge |
Rehabilitative Care (including physical, occupational and speech therapy) |
10% co-payment. Must obtain prior approval. 1 |
20% co-payment. Up to $35 max benefit per visit. Must obtain prior approval. 2 |
No Charge |
No Charge |
Skilled Nursing |
10% co-payment. 1 |
20% co-payment. 2 |
No Charge |
No Charge |
Voluntary Termination of Pregnancy (Medical, Medication and surgical) |
10% co-payment. 1 |
20% co-payment. 2 |
$5 Co-payment |
$75 co-payment |
Benefits Available on an Outpatient Basis |
Ambulance |
10% co-payment 1 |
10% co-payment 2 |
No Charge |
No Charge |
Durable Medical Equipment |
10% co-payment. 1 |
20% 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 |
20% co-payment. 2 |
No Charge |
No Charge |
Immunizations (For Children Under two (2) years of age, refer to well-baby care) |
No Charge |
20% co-payment 2 |
$5 Office Visit Co-payment |
No Charge |
Laboratory Services (When available through or authorized by PCP) |
10% co-payment. 1 |
20% 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 |
20% co-payment 2 |
$5 Office Visit Co-payment |
$5 Office Visit Co-payment |
Oral Surgery Services |
10% co-payment 1 |
10% co-payment 2 |
No Charge |
No Charge |
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility |
10% co-payment 1 |
20% co-payment 2 |
$5 Office Visit Co-payment |
$5 Office Visit Co-payment |
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility |
10% co-payment. 1 |
20% co-payment.2 |
No Charge |
No Charge |
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). |
10% co-payment 1 |
20% co-payment 2 |
$5 Office Visit Co-payment |
$5 Office Visit Co-payment |
Prescription Drugs |
Retail – up to a 30-day supply |
|
|
|
|
Generic |
$0 up to a 30 day supply |
$5* up to a 30 day supply |
$0 up to a 100 day supply |
$0 up to a 30 day supply |
Brand-Name |
$10 up to a 30 day supply |
$15* up to a 30 day supply |
$10 up to a 30 day supply |
$10 up to a 30 day supply |
Mail Order (Maintenance Drugs) – up to a 90-day supply |
|
|
|
|
Generic |
$0 up to a 90 day supply |
N/A |
$0 up to a 100 day supply |
$0 up to a 90 day supply |
Brand-Name |
$20 up to a 90 day supply |
N/A |
$20 up to a 100 day supply |
$20 up to a 90 day supply |
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). |
0% co-payment 1 |
20% 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). |
0% co-payment 1 |
20% co-payment 2 |
No Charge |
No Charge |
1 Subject to the annual deductible. |