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Medical, Dental and Vision

Comparison of Benefits 2008-2009

Plan Providers:

The table below is a summary only. The plan brochure and Evidence of Coverage provide greater detail. In the case of any discrepancies, the plan brochure and Evidence of Coverage language supercedes the summary below.

Benefit Component Kaiser HMO Plan (Low) Kaiser HMO Plan (High) PacifiCare HMO Plan PacifiCare Plus
In-Network		 PacifiCare Plus
Out-of-Network
PCP Required? Yes Yes Yes Yes No
Deductible N/A N/A N/A N/A $500 / $1,000
Out of Pocket Maximum - there will be limitations on which services count towards the OOP, please refer to your actual plan documents for details $2,000 individual

$4,500 family		 $2,000 individual

$4,500 family		 $2,500 individual

$7,500 family		 $2,500 individual

$5,000 family		 $5,000 individual

$10,000 family (excludes deductibles & co-pays)
Coinsurance N/A N/A N/A N/A 30% after deductible
PCP Office Visit Co-pay $25 $20 $25
includes OB/GYN		 $25
includes OB/GYN		 30% after deductible
Specialist Office Visit Co-pay $50 $30 $45 $50 30% after deductible
Allergy Shot Copay $25 $20 $10 $10 30% after deductible
Preventative Care $25 copay PCP $20 copay PCP $25 copay PCP and $45 copay Specialist $25 copay PCP and $50 copay Specialist 30% after deductible, not covered for adult services except mammograms and prostate cancer screenings as necessary
Emergency Room Visit $200 copay (waived if admitted) $150 copay (waived if admitted) $250 (waived if admitted) $200 copay (waived if admitted) $200 copay (waived if admitted)
Ambulance 20% coinsurance up to max of $500 per trip 20% coinsurance up to max of $500 per trip $100 copay per trip $75 copay per trip $75 copay per trip
Hospital Inpatient $500 copay per admit $300 copay per admit $500 per admit $500 per admit 30% after deductible when pre-authorization is obtained; 50% after deductible when not pre-authorized
Hospital Outpatient $100 per visit $100 per admit $250 per visit $250 per visit 30% after deductible
Outpatient Surgery $250 copay per visit $100 copay per visit $250 copay per visit $250 copay per visit 30% after deductible when preauhorization is obtained, 50% after deductible when not preauthorized
MRI, CT, SPECT, PT Scan $100 copay per procedure $100 copay per procedure $100 copay per procedure $75 copay per procedure 30% after deductible
Urgent Care Office Visit (Out-of-Network Area) $50 copay $50 copay $25 copay ($400 contract year maximum benefit) $25 copay ($400 contract year maximum benefit) $25 copay
Maternity Care $25 copay per visit $20 copay per visit $25 copay, one copay per pregnancy $25 copay, one copay per pregnancy $30% after deductible
Chiropractic $25 copay (20 visits per calendar year) $20 copay (20 visits per calendar year) Not Covered PERKS discount available Not Covered PERKS discount available 30% after deductible up to $500 per type of therapy ($1000 max. benefit per contract year, chiro and physical therapy combined)
Mental Health Outpatient $25 copay (20 visits per calendar year) $20 copay (20 visits per calendar year) $0 copay for visits 1 - 5; $45 copay thereafter $0 copay for visits 1 - 5; $50 copay thereafter 30% after deductible (20 visits maximum per contract year)
Prescription Drugs $15/$40 copay generic/brand; 30 day supply Mail order = 2x copay for 90 day supply Self-administered injectables/ specialty drugs 20% with $250 max per fill $15/$30 copay generic/brand; 30 day supply Mail order = 2x copay for 90 day supply Self-administered injectables/ specialty drugs 20% with $250 max per fill $15/$40/$65 copay generic/brand/non-formulary for 30 day supply Mail order - 2x copay for 90 day supply $15/$40/$70 copay generic/brand/non-formulary for 30 day supply Mail order - 2x copay for 90 day supply Applicable copay plus 20% of remaining cost. Mail order not covered.
Outpatient Injectibles Office Administered Selfinjectables/ specialty drugs 20% Office Administered Selfinjectables/ specialty drugs 20% $100 copay $75 copay Not covered
Oxygen/ Durable Medical Equipment (DME) Oxygen covered in full. DME covered at 80% up to $2000 Oxygen covered in full. DME covered at 80% up to $2000 $2000 per year maximum. Oxygen covered at 100%. All other DME covered at 80% (separate $500 per year for podiatric shoe inserts and orthopedic braces) Prosthetic arms and legs are not limited to the maximum $2000 per year maximum. Oxygen covered at 100%. All other DME covered at 80% (separate $500 per year for podiatric shoe inserts and orthopedic braces) Prosthetic arms and legs are not limited to the maximum 30% after deductible $1000 annual max benefit. Prosthetic arms and legs are not limited to the maximum.
Vision Benefit $25 eye exam copay for eye glasses $20 eye exam copay for eye glasses Not covered unless medically necessary. PERKS discounts available Not covered unless medically necessary. PERKS discounts available Not Covered. PERKS discounts available.
Hearing Benefit Not Covered Not Covered Not Covered. PERKS discount available Not Covered. PERKS discount available Not Covered. PERKS discount available
Dental Benefit Not Covered Not Covered Not Covered Not Covered Not Covered
Lifetime Maximum (specific benefits limits may apply) Unlimited (see also specific limits) Unlimited (see also specific limits) Unlimited (see also specific limits) Unlimited (see also specific limits) $1,000,000 (see also specific limits)

NOTE: Benefits and rates are subject to change.