LAPRA 2018/19 Benefits Guide for Active Members

6 2018/2019 LAPRA Medical Plans At-a-Glance The table below provides an overview of the key benefits provided through the LAPRA medical plans. Please refer to the Anthem Blue Cross PPO or HMO, or Kaiser HMO materials for a complete description of benefits including terms of coverage, exclusions and limitations. Benefit Feature Anthem Blue Cross Prudent Buyer PPO Anthem Blue Cross CaliforniaCare Plus HMO (California Residents Only) Kaiser HMO (California Residents Only) Providers PPO Network Non-PPO Network 1 HMO Providers Only 3 HMO Providers Only Calendar Year Deductible $350 per person $700 per family $750 per person $1,500 per family N/A N/A Calendar Year Out-of- Pocket Maximum (includes deductibles and co-pays; excludes co-pays for infertility benefits) Medical Charges: $2,000 per person $6,000 per family (not to exceed $2,000 for any one person) See page 7 f or prescription drug out-of-pocket maximum. Medical Charges: $4,000 per person $12,000 per family (not to exceed $4,000 for any one person) See page 7 for prescription drug out-of-pocket maximum. Medical and Prescription Drug Charges: $1,000 per person $3,000 per family Medical and Prescription Drug Charges: $1,500 per person $3,000 per family Lifetime Max Unlimited Unlimited Unlimited Office Visit 90% 2 70% 2 $20 co-pay $15 co-pay Hospitalization 90% 2 70% 2,4,5 100% 100% Emergency Room 90% 2 after a $150 co-pay (waived if admitted) $150 co-pay (waived if admitted) $150 co-pay (waived if admitted) Urgent Care 90% 2 70% 2 $20 co-pay $15 co-pay Maternity Care 90% 2 70% 2 Doctor visits: $20 co-pay (initial visit only) Facility charges: 100% Doctor visits: 100% Facility charges: 100% Well Baby/ Child Care 100% (up to age 7; not subject to deductible) 70% 2 (up to age 7; not subject to deductible) 100% (up to age 7) 100% (up to age 2) Routine Physical 100% (adults & children over age 7; not subject to deductible) 70% 2 100% (adults & children over age 7) 100% Diagnostic X-ray & Lab Tests 90% 2 70% 2 100% 100% Body Scans (not subject to deductible) 100% after $25 co-pay; up to $250 per calendar yr Not Covered Not Covered Not Covered 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) $20 co-pay (limited to a 60-day period of care after illness or injury; additional visits available when approved by the medical group) $15 co-pay (Chiropractic up to 40 visits per year) Acupuncture 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) $20 co-pay $15 co-pay (Must be referred by your primary care physician) Mental Health/ Chemical Dependency • Outpatient • Inpatient 90% 2 90% 2 70% 2 70% 2,4,5 $20 co-pay 100% $15 co-pay individual therapy/ group therapy: $7 co-pay mental health, $5 co-pay chem dep 100% 1 Benefits are based on the Anthem standard charge. You are responsible for any difference between the amount charged and the maximum allowed amount, plus any deductible and/or coinsurance amount. 2 Subject to calendar year deductible. 3 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. 4 Failure to obtain pre-service authorization may result in a $350 penalty. 5 Covered expense is reduced by 25% for services and supplies provided by a non-contracting hospital.