medical PLans

All Points Benefits (APB) Medical


LAPRA offers you and your family three medical options:


All three plans provide coverage for preventive care, office visits, hospitalization, surgery and prescription drugs. The plans differ in co-payments, coinsurance, out-of-pocket costs, and provider choice. Plan highlights and monthly premiums may be found in your Enrollment Guide.


Anthem Blue Cross CaliforniaCare Plus HMO


The Anthem Blue Cross CaliforniaCare Plus HMO offers comprehensive coverage for a wide range of health care services. Benefits are payable only when you use Anthem Blue Cross HMO providers and facilities. Under the “Plus” benefits, you have the option to choose providers outside of the CaliforniaCare HMO network for certain outpatient services and still receive limited benefits for those services. Refer to your Enrollment Guide for details. There are no deductibles and no claim forms.

You pay a $15 co-pay for most services. The calendar year out-of-pocket co-pay maximum is $1,000 per person and $3,000 per family. The out-of-pocket maximum includes prescription drug co-pays, and excludes co-pays for infertility benefits. You must choose a Primary Care Physician (PCP) from a Participating Medical Group or Independent Practice Association in the Anthem Blue Cross HMO network. Your PCP manages all of your medical care, refers you to specialists as needed, and can help you take advantage of special wellness programs. This plan is only available to California residents.

 

Effective July 1, 2017




Benefit Feature
Anthem Blue Cross CaliforniaCare Plus HMO
(California Residents Only)
Providers
HMO Providers Only1
Calendar Year Deductible
N/A
Calendar Year Out-of-Pocket Max
(excludes co-pays for infertility benefits)
$1,000 per person, $3,000 per family
Lifetime Max
Unlimited
Office Visit
$15 co-pay
Hospitalization
100%
Emergency Room
$150 co-pay (waived if admitted)
Urgent Care
$15 co-pay
Maternity Care
Doctor visits: $15 co-pay (initial visit only)
Facility charges: 100%
Well Baby/ Child Care
(up to age 7)
100%
Routine Physical
(adults and children over age 7)
100%
Diagnostic X-ray & Lab Tests 100%
Body Scans
Not Covered
Physical & Occupational Therapy and Chiropractic Services (additional services may be authorized)
$15 co-pay
(limited to a 60-day period of care after illness or injury; additional visits available when approved by the medical group)
Acupuncture
(24 visits per calendar year)
$15 co-pay
Mental Health/Chemical Dependency
• Outpatient
• Inpatient

$15 copay
100%

1 Your primary care physician can refer you to a specialist when necessary and must approve all care you receive except in the event of an emergency.


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When You Need a Prescription


When you enroll in a LAPRA medical plan, you automatically receive prescription drug coverage as shown in the table below. Note that prescription drugs count towards your medical plan calendar out-of-pocket maximum.

To save money, request that your doctor write your prescriptions for “generic” drugs whenever possible. Generic drugs are often the therapeutic equivalent of their brand-name counterparts, but cost significantly less.

You can purchase up to a 90-day supply of most maintenance drugs at a retail pharmacy. Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. Also, women's generic prescription contraceptives are covered with a $0 co-pay to comply with requirements of the Affordable Care Act.




Prescription Drugs
Anthem Blue Cross CaliforniaCare Plus HMO
(California Residents Only)

Retail Pharmacy
• Generic
1
• Brand

• Maintenance Drugs
• Injectables
2
• Retail Supply

 

$15 co-pay
$25 co-pay
2 co-pays (90-day supply)

20% co-pay,1 max $150/prescription
Up to 30 days (90 days for maintenance drugs
3)

Mail Order
• Generic
1
• Brand
• Injectables
2
• Mail Order Supply

1-30 day supply / 31-90 day supply
$15 co-pay / $30 co-pay
$25 co-pay / $50 co-pay
20% co-pay,
1 max $150/script / 20% co-pay, max $300/script
Up to 90 days


1 $0 co-pay for women's prescription contraceptives.

2 20% co-pay does not apply to insulin. Regular co-pays apply.

3 Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. To determine if your medication qualifies as a maintenance drug, contact Anthem Blue Cross at 800-700-2541. Maintenance drugs do not include any controlled substances, smoking cessation or weight management medications.


 

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CaliforniaCare Plus Program

Under the "Plus" benefits, you have the option to choose providers outside the CaliforniaCare HMO network for certain outpatient service and still receive limited benefits for those services. You have the choice of using Prudent Buyer Plan providers or non-participating providers. If you use Prudent Buyer Plan providers, you cost will be less.

Premium Rates


Click on a link below for the 2016-2017 or 2017-2018 retiree medical and dental premium rates. Your cost is the monthly premium rate minus the Pension Department subsidy, based on your retirement date, age and years of service.

Note: If you or any of your covered dependents are eligible for and enroll in Medicare Part D through a plan other than the LAPRA Blue Cross plans, you premium costs may be higher. You are eligible to enroll in Medicare Part D through the LAPRA Blue Cross plans if you are enrolled in Medicare Parts A and B.

 

  





This brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Anthem Blue Cross contract. Please refer to your plan’s Evidence of Coverage for details on your benefits.

 


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