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.
The Anthem PPO Plan is a Preferred Provider Organization (PPO) that gives you the option to see any provider (participating providers or non-participating providers) whenever you need care. If saving health care dollars is important to you, you will want to stay in-network by using only PPO doctors and hospitals. The Prudent Buyer PPO network is the largest provider network in California.
PPO network providers are doctors, hospitals, pharmacies, labs, etc. that participate in the Anthem
Prudent Buyer PPO network and have agreed to provide services at pre-negotiated reduced rates. When you use PPO network providers, you receive the highest level of benefits at the lowest possible cost. You are not required to choose a primary care physician and you can see doctors and specialists within the network without a referral. PPO providers file all claims for you.
After a PPO network calendar year deductible of $350 per person, or $650 per family, the Plan pays 90% of most covered PPO network services and you pay 10%.
After a separate non-PPO network calendar year deductible of $750 per person, or
$1,500 per family, the Plan pays 70% of most covered services and you pay 30%. The out-of-pocket calendar year maximum for PPO network services is $2,000 per person
or $6,000 per family (not to exceed $2,000 for any one individual). A separate out-of-pocket calendar year maximum of $4,000 per person or $12,000 per family (not to exceed $4,000 for any one individual) applies for non-network services.
The out-of-pocket maximum includes deductibles and medical and prescription drug
co-pays, and excludes co-pays for infertility benefits.
IMPORTANT: When using a non-network provider under the Anthem PPO
Plan, the maximum allowable charge is based on the customary and reasonable charge for professional services as determined by Anthem. Members are responsible for any difference between the non-network provider’s actual charge and the maximum allowable charge, as well as any deductible and/or coinsurance percentage.
Effective July 1, 2024
| Benefit Feature | Anthem PPO |
|
|---|---|---|
| Providers | PPO Network |
Non-PPO Network1 |
| Calendar Year Deductible | $350 per person, $700 per family |
$750 per person, $1,500 per family |
| Calendar Year Out-of-Pocket Max (includes deductibles and medical co-pays; excludes co-pays for infertility benefits) | $2,000 per person $6,000 per family (not to exceed $2,000 for any one individual) |
$4,000 per person $12,000 per family (not to exceed $4,000 for any one individual) |
| Lifetime Max | Unlimited |
Unlimited |
| Office Visit | 90%2 |
70%2 |
| Hospitalization | 90%2 |
70%2,3,4 |
| Emergency Room | 90% after $150 co-pay per visit (waived if admitted) |
|
| Urgent Care | 90%2 |
70%2 |
| Maternity Care | 90%2 |
70%2 |
| Well Baby/ Child Care (up to age 7; not subject to deductible) |
100% |
70%2 |
| Routine Physical (adults; and children over age 7; not subject to deductible) |
100% |
Not covered |
| Diagnostic X-ray & Lab Tests | 90%2 | 70%2 |
| Body Scans (not subject to deductible) |
100% (no co-pay) up to $500 every 2
years for enrollee and spouse or registered domestic partner |
|
| Physical & Occupational Therapy and Chiropractic Services (additional services may be authorized) | 90%2 (24 visits per calendar yr combined PPO Network & Non-PPO Network) |
70%2 (24 visits per calendar yr combined PPO Network & Non-PPO Network) |
| Acupuncture (24 visits per calendar year combined PPO Network & Non-PPO Network) |
90%2 (up to $30 per visit) |
70%2 (up to $30 per visit) |
| Mental Health/Chemical Dependency • Outpatient • Inpatient |
90%2 90%2 |
70%2 70%2,3,4 |
1 You may be responsible for paying the difference
between the maximum allowed amount and the amount the non-participating provide
or other health care provider charges. This amount can be significant. Choosing
a participating provider will likely result in lower out of pocket costs to you.
2 Subject to calendar year deductible.
3 Failure to obtain pre-authorization
may result in a $350 penalty.
4 Covered expense is reduced by 25% if a service or supply is provided by a non-contracting hospital.
When you enroll in a LAPRA medical plan, you automatically receive prescription drug coverage as shown in the table below. Note that under the Anthem Blue Cross PPO plan, there is a separate prescription drug 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.
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.
| Prescription Drugs | Anthem PPO |
|---|---|
| Calendar Year Prescription Drug Out-of-Pocket Maximum |
$4,850 per
person $7,700 per family |
Retail Pharmacy • Non-formulary • Maintenance Drugs3 |
$15 co-pay1 $40 co-pay Up to 30 days (90 days for maintenance drugs3) |
Mail Order • Specialty Drugs4 • Mail Order Supply |
1-30 day supply / 31-90
day supply $40 co-pay
/ $80 co-pay |
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.
Los Angeles Protective League Member
Assistance Program
All members and their families are encouraged to utilize the Los
Angeles Police Protective League's Member Assistance Program
(MAP) prior to accessing your selected medical plan. The MAP
provides 10 face-to-face counseling sessions per family member,
per incident, per year covered at no cost to you. Download a MAP
flyer
here for more information.
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 tables below reflects the member cost per pay period effective July 1, 2024.
| Anthem PPO Premium Rates Effective July 1, 2024 | |
|---|---|
Cost Per Pay-Period |
|
Single |
$0.00 |
2-Party |
$0.00 |
Family |
$76.62 |
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.