Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Anthem Blue Card (OOS) PPO
Plan Information
Plan Name: Anthem Blue Card (OOS) PPO
Policy Number: XXXX
Effective Date: 01/01/2025
Network: Anthem Blue Cross: Prudent Buyer PPO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$150 per individual, maximum of 3 per family
Out-of-Pocket Max (Individual/Family)
$1,000/$2,000
Preventive Care
$0
Primary Care Visit
$15 copay after deductible
Specialist Visit
$15 copay after deductible
Urgent Care
$15 copay after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$15 copay
Non-Preferred Brand
$15 copay
Specialty
$15 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10 copay
Preferred Brand
$15 copay
Non-Preferred Brand
$15 copay
Specialty
$15 copay
Out-of-Network
Deductible (Individual/Family)
$150 per individual, maximum of 3 per family
Out-of-Pocket Max (Individual/Family)
$1,000/$2,000
Preventive Care
$0
Primary Care Visit
$15 copay after deductible
Specialist Visit
$15 copay after deductible
Urgent Care
$15 copay after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay, then 50% coinsurance
Preferred Brand
$15 copay, then 50% coinsurance
Non-Preferred Brand
$15 copay, then 50% coinsurance
Specialty
$15 copay, then 50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Important Contacts
Anthem Blue Cross PPO
Plan Information
Plan Name: Anthem Blue Cross PPO
Policy Number: XXXX
Effective Date: 01/01/2025
Network: Anthem Blue Cross: Prudent Buyer PPO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$150 per individual, maximum of 3 per family
Out-of-Pocket Max (Individual/Family)
$1,000/$2,000
Preventive Care
$0
Primary Care Visit
$15 copay (deductible does not apply)
Specialist Visit
$15 copay (deductible does not apply)
Urgent Care
$15 copay (deductible does not apply)
Emergency Room
10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$15 copay
Non-Preferred Brand
$15 copay
Specialty
$15 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10 copay
Preferred Brand
$15 copay
Non-Preferred Brand
$15 copay
Specialty
$15 copay
Out-of-Network
Deductible (Individual/Family)
$150 per individual, maximum of 3 per family
Out-of-Pocket Max (Individual/Family)
$2,000/$5,000
Preventive Care
30% coinsurance after deductible
Primary Care Visit
30% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
30% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay, then 50% coinsurance
Preferred Brand
$15 copay, then 50% coinsurance
Non-Preferred Brand
$15 copay, then 50% coinsurance
Specialty
$15 copay, then 50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Important Contacts
Anthem Blue Cross HMO
Plan Information
Plan Name: Anthem Blue Cross HMO
Policy Number: XXXX
Effective Date: 01/01/2025
Network: Anthem Blue Cross: California Care HMO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,000/$3,000
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$5 copay
Urgent Care
$5 copay
Emergency Room
$50 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$10 copay
Specialty
$10 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$10 copay
Specialty
$10 copay
Out-of-Network
Deductible (Individual/Family)
Embedded with In-Network
Out-of-Pocket Max (Individual/Family)
Embedded with In-Network
Preventive Care
Not covered
Primary Care Visit
Not covered
Specialist Visit
Not covered
Urgent Care
$5 copay
Emergency Room
$50 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay, then 50% coinsurance
Preferred Brand
$10 copay, then 50% coinsurance
Non-Preferred Brand
$10 copay, then 50% coinsurance
Specialty
$10 copay, then 50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Important Contacts
Kaiser Traditional HMO
Plan Information
Plan Name: Kaiser Traditional HMO
Policy Number: XXXX
Effective Date: 01/01/2025
Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$5 copay
Urgent Care
$5 copay
Emergency Room
$50 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5
Preferred Brand
$10
Non-Preferred Brand
$10
Specialty
$10
Mail-Order Rx (Up to 100-Day Supply)
Generic
$5
Preferred Brand
$10
Non-Preferred Brand
$10
Specialty
Not covered