HomeMy WebLinkAboutOtay Plan Comparison Brochure800.537.7790 • sdrma.org
MEDICAL BENEFITS SUMMARY2
DEDUCTIBLES/COINSURANCE Gold PPO EPO
Calendar Year Deductible(s) (Individual/Family)$500 / $1,000 $300 / $600
Maximum Medical Out of Pocket (Individual/Family)$2,000 / $4,000 $1,300 / $2,600
Medicare Medical Maximum Out of Pocket $1,500 / $3,000 $1,000 / $2,000
Services/Coverages Participating Providers (You Pay)
Non-Participating Providers (You Pay)
Participating Providers (You Pay)
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
20%50% up to $600
per day No Charge
Outpatient Hospital 20%50% up to $350
per day $30 co-pay
Ambulatory Surgery Center 10%;
Deductible Waived
50% up to $350
per day
No Charge;
Deductible Waived
Emergency Room $100 co-pay + 20%
(co-pay waived if admitted)
$100 co-pay (co-pay
waived if admitted)
Urgent Care $20 co-pay 50%$30 co-pay
Physician Benefits (office visits)$20 co-pay 50%$30 co-pay
Preventative Care No Charge Not Covered No Charge
Lab/X-ray
$0 ($25 co-pay + 20%
if services provided
by Hospital)
50% (up to
$350/ per day
within Hospital)
$0 ($25 co-pay if services provided by Hospital)
Complex Imaging (CT, PET, MRI, etc.)
20% ($100 co-pay +
20% if services
provided by Hospital)
50% up to
$800 per day $0 ($100 co-pay if services provided by Hospital)
Acupuncture (26 visits per calendar year/combined
with Chiropractic)20%$30 co-pay
Chiropractic Services (26 visits per calendar
year/combined with Acupuncture)
20% up to $50
per visit
50% up to $25
per visit $30 co-pay
Prescription Drugs
Active/Early Retiree Plans Only Navitus*Navitus*
Prescription Maximum Out of Pocket $4,600 / $9,200 $5,300 / $10,600
(At Participating Pharmacies only)Generic / Brand / Non-Formulary / Specialty Generic / Brand / Non-Formulary / Specialty
Retail - 30 day supply $5 / $30 / $45 / 30% (max co-pay $150)$10 / $20 / $45 / 30% (max co-pay $150)
Mail Order - 90 day supply $10 / $75 / $112.50 / 30% (max co-pay $300)$15 / $50 / $112.50 / 30% (max co-pay $150)
Brand / Non-Formulary / Specialty Deductible
(Individual / Family)None $200
THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION
OF COVERAGE BENEFITS AND LIMITATIONS. NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.
PLAN SUMMARY – BLUE SHIELD
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800.537.7790 • sdrma.org
MEDICAL BENEFITS SUMMARY 3
DEDUCTIBLES/COINSURANCE Access+ HMO 15
Calendar Year Deductible(s) (Individual/Family)None
Maximum Medical Out of Pocket (Individual/Family)$1,500 / $3,000
Medicare Medical Maximum Out of Pocket Non-Applicable
Services/Coverages Participating Providers (You Pay)
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
No Charge
Outpatient Hospital $100 / Surgery
Ambulatory Surgery Center No Charge
Emergency Room $50 co-pay (co-pay waived if admitted)
Urgent Care $15 co-pay
Physician Benefits
(office visits)
Note: A woman may self-refer to an OB/GYN or family
practice physician in her personal physician’s medical
group or IPA for OB/GYN services.$15 co-pay
Preventative Care No Charge
Lab/X-ray No Charge
Complex Imaging (CT, PET, MRI, etc.)No Charge
Acupuncture (30 visits per calendar year/combined
with Chiropractic)$10 co-pay
Chiropractic Services (30 visits per calendar
year/combined with Acupuncture)$10 co-pay
Prescription Drugs
Active/Early Retiree Plans Only Navitus
Prescription Maximum Out of Pocket $5,100 / $10,200
(At Participating Pharmacies only)Generic / Brand / Non-Formulary / Specialty
Retail - 30 day supply $5 / $10 / $25 / 20% (max co-pay $100)
Mail Order - 90 day supply $10 / $20 / $50 / 20% (max co-pay $100)
Brand Deductible (Individual / Family)None
THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A
DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.
PLAN SUMMARY – BLUE SHIELD
800.537.7790 • sdrma.org
MEDICAL BENEFITS SUMMARY4
DEDUCTIBLES/COINSURANCE/MAXIMUM Kaiser HMO 15
Calendar Year Deductible(s) (Individual/Family)None
Maximum Medical Out of Pocket (Individual/Family)$1,500 / $3,000
Medicare Medical Maximum Out of Pocket Non-Applicable
Services/Coverages Participating Providers (You Pay)
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
No Charge
Outpatient Hospital $15 / Surgery
Ambulatory Surgery Center $15 / Surgery
Emergency Room $50 co-pay
(co-pay waived if admitted)
Urgent Care $15 co-pay
Physician Benefits (office visits)$15 co-pay
Preventative Care No Charge
Lab/X-ray No Charge
Complex Imaging (CT, PET, MRI, etc.)No Charge
Acupuncture (30 visits per calendar year/combined
with Chiropractic)$10 co-pay
Chiropractic Services (30 visits per calendar
year/combined with Acupuncture)$10 co-pay
Prescription Drugs
Active/Early Retiree Plans Only Kaiser
(At Participating Pharmacies only)Generic / Brand / Specialty
Retail - 30 day supply $5 / $20 / $20
Mail Order - 100 day supply $10 / $40
Brand Deductible (Individual / Family)None
THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A
DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.
PLAN SUMMARY – KAISER
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800.537.7790 • sdrma.org
MEDICAL BENEFITS SUMMARY 5
DEDUCTIBLES/COINSURANCE/MAXIMUM Kaiser Permanente Senior Advantage (KPSA)
HMO with Part D
Calendar Year Deductible(s) (Individual/Family)None
Maximum Medical Out of Pocket (Individual/Family)$1,000 / $2,000
Medicare Medical Maximum Out of Pocket Non-Applicable
Services/Coverages Participating Providers
(You Pay)
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
No Charge
Outpatient Hospital $10 / Surgery
Ambulatory Surgery Center $10 / Surgery
Emergency Room $50 co-pay
(co-pay waived if admitted)
Urgent Care $10 co-pay
Physician Benefits (office visits)$10 co-pay
Preventative Care No Charge
Lab/X-ray No Charge
Complex Imaging (CT, PET, MRI, etc.)No Charge
Acupuncture (30 visits per calendar year/combined
with Chiropractic)$10 co-pay
Chiropractic Services (30 visits per calendar
year/combined with Acupuncture)$10 co-pay
Prescription Drugs Kaiser
(At Participating Pharmacies only)Generic / Brand
30 day supply $5 / $20
31 – 60 day supply $10 / $40
61 - 100 day supply $15 / $60
(Mail Order Refills only)Generic / Brand
30 day supply $5 / $20
31 – 100 day supply $10 / $40
THIS SUMMARY IS INTENDED TO COMPARE COVERAGE BENEFITS ONLY. THE ACTUAL PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION
OF COVERAGE BENEFITS AND LIMITATIONS. NON-PARTICIPATING PROVIDER MEMBER COST MAY NOT APPLY TO MAXIMUM OUT OF POCKET COSTS.
PLAN SUMMARY – KAISER – MEDICARE