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 $20 co-pay for most services. The calendar year out-of-pocket co-pay maximum is $1,000 per person and $3,000 per family. 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, 2018




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 (includes prescription drug co-pays; excludes co-pays for infertility)
$1,000 per person, $3,000 per family
Lifetime Max
Unlimited
Office Visit
$20 co-pay
Hospitalization
100%
Emergency Room
$150 co-pay (waived if admitted)
Urgent Care
$20 co-pay
Maternity Care
Doctor visits: $20 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)
$20 co-pay
(limited to a 60-day period of care after illness or injury; additional visits available when approved by the medical group)
Acupuncture
$20 co-pay
Mental Health/Chemical Dependency
• Outpatient
• Inpatient

$20 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.

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. Under the Anthem Blue Cross PPO plan, if a geenric drug is availalbe and a brand-name drug is dispensed because your physician specifies "dispense as written," you will pay the applicalbe co-pay for the brand name drug you receive. See footnote #2 below if your physician does not specify "dispense as written."

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 Prudent Buyer PPO
Calendar Year Prescription Drug Out-of-Pocket Maximum

$4,850 per person
$7,700 per family
(not to exceed $4,850 for any one person)

Retail Pharmacy
• Generic1
• Brand2

Non-formulary

• Maintenance Drugs3
• Specialty Drugs4
• Retail Supply

 

$15 co-pay
$25 co-pay

$40 co-pay
2 co-pays (90-day supply)
 20% co-pay,1 max $150/prescription

Up to 30 days (90 days for maintenance drugs3)

Mail Order
• Generic1
• Brand
• Non-formulary

• Specialty Drugs4

• Mail Order Supply

1-30 day supply / 31-90 day supply
$15 co-pay / $30 co-pay
$25 co-pay / $50 co-pay

$40 co-pay / $80 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 Under the Anthem Blue Cross PPO plan, you will have to pay the co-pay for the generic drug plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug, but not more than 50% of the average cost for the tier that the brand name drug is in.

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.

4 20% co-pay does not apply to insulin. Regular co-pays apply.



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.

 


Los Angeles Protective League Employee Assistance Program

All members and their families are encouraged to utilize the Los Angeles Police Protective League's Employee Assistance Program (EAP) prior to accessing your selected medical plan. The EAP provides 10 sessions covered at no cost to the family.

Premium Rates


Your cost for Medical is based on your selected plan and coverage category as well as the amount of the City of Los Angeles subsidy. The table below reflects the member cost per pay period effective July 1, 2018.



Anthem Blue Cross CaliforniaCare Plus HMO Premium Rates
Cost Per Pay-Period
Single
$0.00
2-Party
$0.00
Family
$50.90


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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