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.


Kaiser HMO


Kaiser HMO benefits are payable only when you use Kaiser providers and facilities. You must select a primary care physician to manage your health care, including referrals to specialists. You may self-refer to another Kaiser physician for routine and preventive care, well baby visits or OB/Gyn care. The calendar year out-of-pocket maximum is $1,500 per person and $3,000 per family. The out-of-pocket maximum includes prescription drug co-pays. If you’d like a second opinion, you can ask to see another Kaiser physician. You may change your Kaiser physician at any time for any reason.

With the Kaiser HMO, there are no deductibles and no claim forms. You pay a $15 co-pay for most services. Worldwide emergency benefits are available when you travel away from home. This plan is only available to California residents.

 

Effective July 1, 2017



Benefit Feature
Kaiser HMO
(California Residents Only)
Providers
HMO Providers Only
Calendar Year Deductible
N/A
Calendar Year Out-of-Pocket Max (includes prescription drug co-pays)
$1,500 per person, $3,000 per family
Lifetime Max
Unlimited
Office Visit
$15 co-pay
Hospitalization
100%
Emergency Room
$75 co-pay (waived if admitted)
Urgent Care
$15 co-pay
Maternity Care
Doctor visits: 100%
Facility charges: 100%
Well Baby/ Child Care
(up to age 2)
100%
Routine Physical
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
(Chiropractic up to 40 visits per year)
Acupuncture
$15 co-pay

Mental Health/Chemical Dependency
• Outpatient
• Inpatient


$15 co-pay individual therapy/
$7 co-pay group therapy
100%

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When You Need a Prescription


When you enroll in the Kaiser HMO, you automatically receive prescription drug coverage as shown in the table below. Note that prescription drugs count towards your medical plan calendar year 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. Also, women's generic prescription contraceptives are covered with a $0 co-pay to comply with requirements of the Affordable Care Act.

 



Prescription Drugs
Kaiser HMO
(California Residents Only)

Retail Pharmacy
• Generic
1
• Brand
• Injectables
• Retail Supply


$15 co-pay
$30 co-pay
n/a
Up to 30 days

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

1-30 day supply / 31-100 day supply
$15 co-pay / $30 co-pay
$30 co-pay / $60 co-pay
n/a
Up to 100 days


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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.

The Kaiser HMO rate table reflects the various health plan options available to retirees who elect Kaiser and are entitled to Medicare. Retirees enrolled in the Senior Advantage Plan must be enrolled in, and assign, Medicare Parts A & B to Kaiser and effective January 1, 2006, must purchase Medicare Part D through Kaiser. Members enrolled in Parts B and D only may purchase Part A from Kaiser Permanente. The Federal Medicare Agency, the Centers for Medicare and Medicaid Services (CMS), establishes eligibility requirements that impact members' cost and condition of enrollment. It is important to note that you must purchase and assign your Medicare benefits to Kaiser or be reclassified into an unknown or unassigned category which will significantly affect your cost as indicated below.

If you or any of your covered dependents are eligible for, and enroll in, Medicare Part D through a plan other than the LAPRA Kaiser plan, your premium costs will be higher. It is important to note that you must assign all of your Medicare benefits to Kaiser or be reclassified into an unknown or unassigned rate category, which will significantly affect your cost as indicated below. To enroll in Kaiser Senior Advantage, you must be enrolled in Medicare Parts A, B and D or B and D only and assign your benefits to Kaiser.

 

  







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

 


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