| Medical plan options | Anthem Blue Cross HMO | Kaiser Permanente | |||
|---|---|---|---|---|---|
| Tier 1 USC faculty/facilities (Anthem Blue Cross/BlueCard for covered persons up to 26 years of age) |
Tier 2 Anthem Blue Cross Prudent Buyer/BlueCard providers |
Tier 3 Non-Network |
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| Annual deductible | None | None | None | None | None |
| Annual out of pocket maximum | |||||
| –Individual | $1,000 | $2,500 | $10,000 | $1,000 | $1,500 |
| –Family | $3,000 (100% thereafter) | $7,500 (100% thereafter) | $30,000 (100% of UCR thereafter) | $3,000 | $3,000 |
| Lifetime maximum benefit | None | None | None | None | None |
| Office visits | You pay $10 | You pay $20 | Plan pays 50% of UCR You pay remainder of charges |
You pay $20 | You pay $25 primary care $50 specialist |
| Preventive care* | Plan pays 100% | Plan pays 100% | Plan pays 50% of UCR You pay remainder of charges |
Plan pays 100% | Plan pays 100% |
| Prescription drugs | If prescription is filled at a Network pharmacy, your copay for a 30-day supply is:
Mail service available on maintenance medications but copays are the same |
If filled at a non-Network pharmacy, the Plan will reimburse 50% of the Plan's CVS Caremark contracted rate Reimbursement request must be received within 60 days of fill |
You pay $10 per prescription for generic drugs and $25 per prescription for brand name formulary drugs and 45% of cost for brand name non-formulary drugs at participating pharmacies | You pay $15 per prescription for generic drugs and $35 per prescription for brand name drugs (up to 30-day supply) at Kaiser Permanente pharmacy | |
| Maternity (doctor only) | You pay $10 | You pay $20 | Plan pays 50% of UCR You pay remainder of charges |
You pay $20 per office visit** | You pay $10 for prenatal care and first post-partum |
| Well Baby Care | Plan pays 100% newborn exam and circumcision at hospital | No charge | No charge | ||
| No charge | No charge | Plan pays 50% of UCR per office visit You pay remainder of charges |
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| Emergency care | Not available | You pay $100 copay (waived if admitted) | You pay $100 copay (waived if admitted) and any charges above 100% of UCR | You pay $100 copayment, waived if directly admitted to hospital | You pay $100 copayment, waived if directly admitted to hospital |
| Urgent Care Centers | Not available | You pay $35 copay | Plan pays 50% of UCR You pay remainder of charges |
You pay $20 copay | You pay $35 copay |
| Ambulance (ground) |
Not available | Plan pays 80% You pay 20% |
Plan pays 80% of UCR You pay remainder of charges |
Plan pays 100% | You pay $50 |
| Inpatient hospital expenses | |||||
| All hospital admissions are subject to a Pre-Hospital Review Program. Benefits are reduced by 50% if program is not followed. | You pay $250 copay per admission | You pay $250 copay per admission | |||
| You pay $100 per day copay ($500 copay maximum per admission) | You pay $150 per day copay ($750 copay maximum per admission) | You pay $200 per day copay ($1,000 copay maximum per admission) plus all charges in excess of 50% UCR | |||
| –Skilled Nursing Facility | Not available | You pay $150 per day copay ($750 copay maximum per admission) | You pay $200 per day copay ($1,000 copay maximum per admission) plus 50% of remainder of charges Plan pays 50% of UCR |
Plan pays 100%, up to 100 days per calendar year | You pay $250 copay per admission Plan pays 100%, up to 100 days per calendar year |
| Limited to 100 days per calendar year regardless of cause | |||||
| –Surgery/doctor visits | Plan pays 90% You pay 10% |
Plan pays 80% You pay 20% |
Plan pays 50% of UCR You pay remainder of charges |
No charge | No charge |
| Outpatient surgery expenses | |||||
| —Facility | You pay $100 copay | You pay $150 copay | You pay $200 copay; Plan pays 50% of UCR up to $2,700 You pay remainder of charges |
You pay $250 copay | You pay $100 copay |
| —Doctor | Plan pays 90% You pay 10% |
Plan pays 80% You pay 20% |
Plan pays 50% of UCR You pay remainder of charge |
No charge | No charge |
| Blood, plasma | Plan pays 90% You pay 10% |
Plan pays 80% You pay 20% |
Plan pays 50% of UCR You pay remainder of charges |
Plan pays 100% | Plan pays 100% if replaced |
| Authorized home health care | Not available | Plan pays 80% You pay 20% |
Plan pays 50% of UCR | You pay $20 per visit (Limited to 100 visits per calendar year) | Plan pays 100% for up to 100 visits per calendar year |
| Up to 100 visits per person each year | |||||
| Durable medical equipment | Not available | Plan pays 80% You pay 20% |
Plan pays 50% of UCR You pay remainder of charges |
Plan pays 100% in most instances | Plan pays 100% in most instances |
| No coverage if not within Plan description Over $2,000 requires preauthorization |
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| Hospice care | Plan pays 100% | Plan pays 100% | Plan pays 100% of UCR | Plan pays 100% | Plan pays 100% |
| Mental health and substance abuse | |||||
| —In hospital | You pay $100 per day copay ($500 copay maximum per admission) | You pay $150 per day copay ($750 copay maximum per admission) | You pay $200 per day copay ($1,000 copay per admission) plus 50% co-insurance | Mental health and substance abuse: You pay $250 per admission (preauthorization required). You pay $20 copay for physician hospital visits | Mental health and substance abuse: You pay $250 copay per admission Transitional residential recovery services: $100 copay per admission |
| —Out of hospital | You pay $10 copay | You pay $20 copay | Plan pays 50% of UCR (80% of UCR for covered person under 26 years of age) You pay remainder of charges |
Mental health and substance abuse: You pay $20 Pre-service review required after 12th visit |
Mental health: You pay $25 per visit and $12 for group visits Substance abuse: $25 per visit for individual therapy; $12 for group |
| Child immunizations | Plan pays 100% up to age 26 | No charge | No charge | ||
| Routine eye exams | Provided by Vision Service Plan (VSP). One eye exam every calendar year. VSP provider: $10 copay. Non-VSP provider: Reimbursed up to $45 | You pay $20 per exam | You pay $25 per exam | ||
| Eyeglasses/contact lenses | Provided by Vision Service Plan (VSP Choice Network). Lenses every calendar year and one pair of frames every other calendar year VSP: Lenses and/or frames $15 copay; frames covered up to $170 Non-VSP: Frames reimbursed up to $55; lenses reimbursed from $45 to $125 Contact lenses (in lieu of lenses and frames): VSP and non-VSP, reimbursed up to $150 Maximum you will pay for laser eye surgery with a VSP provider: $1,500 per eye for PRK; $1,800 per eye for LASIK; $2,300 per eye for Custom LASIK. Non VSP: No benefit |
None | None | ||
| Coverage in foreign countries | Yes | Yes | Yes | Yes, full coverage for emergencies, subject to copays | |
| Coordination with other plans | Yes | Yes | Yes | Yes | Yes |
| Convertible to individual policy if under 65† | No | No | No | Yes | Yes |
| Convertible to Medicare Supplement or Medicare Advantage at retirement | Yes, to USC Senior Care or other plans with Medicare Part A and B | Yes, with Medicare A and B | Yes, with Medicare A and B | ||
| † (following COBRA) UCR=Usual, customary and reasonable charges. *Includes certain childhood immunizations, adult screenings and certain adult immunizations |
**Healthcare Partners Medical Group does not deliver at Huntington Memorial Hospital. | ||||