Member services 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-866-641-1689 1-800-464-4000 Web site www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.anthem.com/ca/llns/ www.my.kp.org/llns HSA Funding N/A N/A N/A N/A $750 Individual; $1,500 Family N/A Annual deductible: Individual/Family Coinsurance percentage Out-of-pocket maximum: Individual/Family Lifetime limit Need to file claims Ability to self-refer to OB/GYN Ability to self-refer to specialists In Network - $300 Individual; $900 Family; does not include copays Out of Network - $500 Individual; $1,500 Family In Network - 80% covered ; Customary In Network - $2,500 Individual; $7,500 Family; in & out-ofnetwork maximums are includes deductible and copays; excludes Pharmacy copays Out of Network - $7,000 Individual; $21,000 Family; in & out-of-network maximums are includes deductible and copays; excludes Pharmacy copays In Network - Limit does not Out of Network - Limit does not In Network - $500 Individual; $1,500 Family Out of Network - $1,000 Individual; $3,000 Family In Network - 80% covered until out-of-pocket maximum is met until out-of-pocket maximum is met; subject to Reasonable and Customary In Network - $3,000 Individual; $9,000 Family; in & out-ofnetwork maximums are excludes Pharmacy copays Out of Network - $6,000 Individual; $18,000 Family; in & out-of-network maximums are excludes Pharmacy copays In Network - Limit does not Out of Network - Limit does not In Network - $3,500 Individual; $6,000 Family; combined in/outof-network; no paid for any member of a family unless $6,000 deductible is met Out of Network - $3,500 Individual; $6,000 Family; combined in/out-of-network; no paid for any member of a family unless $6,000 In Network - 80% covered until out-of-pocket maximum is met until out-of-pocket maximum is met; subject to Reasonable and Customary In Network - $5,000 Individual; $10,000 Family; in & out-ofnetwork maximums are includes deductible and Rx maximum allowed amount Out of Network - $10,000 Individual; $20,000 Family; in & out-of-network maximums are includes deductible and Rx maximum allowed amount In Network - Limit does not Out of Network - Limit does not $0 Individual; $0 Family $1,000 Individual; $3,000 Family; includes copays; excludes Pharmacy copays Limit does not In Network - $1,500 Individual; $3,000 Family; no paid for any member of a family unless $3,000 deductible is met Out of Network - $3,000 Individual; $6,000 Family; no for any member of a family unless $6,000 deductible is met In Network - until out-of-pocket maximum is met until out-of-pocket maximum is met; subject to Reasonable and Customary In Network - $3,000 Individual; $6,000 Family; in & out-ofnetwork maximums are includes deductible and Rx maximum allowed amount Out of Network - $6,000 Individual; $12,000 Family; in & out-of-network maximums are includes deductible and Rx maximum allowed amount In Network - Limit does not Out of Network - Limit does not $0 Individual; $0 Family 100% covered $1,500 Individual; $3,000 Family; medical and Rx copays included; excluding durable medical equipment and infertility services Limit does not In-Network: No In-Network: No In-Network: No In-Network: No No (In-Network) Not Applicable Out-of-Network: Yes Out-of-Network: Yes Out-of-Network: Yes Out-of-Network: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Required only for Emergency Services received outside of Permanente Yes Check with your guidebook to see if your facility has departments that don't require a referral
Ability to self-refer to specialists Anthem Blue YesCross Plus Anthem Blue YesCross PPO Anthem Blue YesCross Core Anthem Blue Yes Cross HDHP
Out-of-area dependent Out-of-area participant Primary doctor office visit Specialist office visit Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes In Network - $25 copay ; and Customary In Network - $35 copay ; and Customary after ; subject after ; subject after ; subject after ; subject $25 copay $35 copay after ; subject after ; subject Refer to disclosure form and evidence of for Refer to disclosure form and evidence of for $25 copay $25 copay In Network - 100% covered In Network - 100% covered In Network - 100% covered 100% covered In Network - 100% covered 100% covered; for preventive Annual physical exam ; and Customary Out of Network - 100% covered; deductible waived; birth thru age six; 60% covered age seven and older; subject after ; subject after ; subject Well-woman exam (includes pap) preventive ; and Customary preventive after ; subject preventive after ; subject preventive after ; subject Mammogram Immunizations (child) In Network - Diagnostic: 80% covered after ; ; and Customary preventive ; and Customary In Network - Diagnostic: 80% covered after ; after ; subject preventive after ; subject In Network - Diagnostic: 80% covered after ; negotiated rates; 100% covered for preventive after ; subject preventive after ; subject Diagnostic: ; In Network - Diagnostic: 90% covered after ; after ; subject preventive after ; subject
Cancer screenings Cardiovascular screenings Allergy tests and treatments Outpatient surgery Outpatient laboratory services Outpatient X-ray preventive ; diagnostic: covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD Out of Network - Covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD In Network - Diagnostic test/diagnostic treatment: $25 copay PCP, $35 copay Specialist; allergy injections 100% covered Out of Network - Diagnostic test/diagnostic treatment: 60% covered; after deductible is met; subject to Reasonable and Customary ; and Customary ; and Customary ; and Customary preventive ; diagnostic: covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD Out of Network - Covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD In Network - Diagnostic test/diagnostic treatment: 80% covered after ; allergy injections 100% covered Out of Network - Diagnostic test/diagnostic treatment: 60% covered after ; Customary after ; subject after ; subject after ; subject preventive ; diagnostic: covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD Out of Network - Covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD Covered under Medical or Routine Physical exam as appropriate In Network - Diagnostic test/diagnostic treatment: 80% covered after Out of Network - Diagnostic test/diagnostic treatment: 60% covered after ; Customary after ; subject ; benefit limited to $350/visit after ; subject after ; subject ; diagnostic: covered as any other illness; for Cancer Clinical Trials refer to EOC/SPD Diagnostic test/diagnostic treatment: $25 copay PCP, $35 copay Specialist; allergy injections 100% covered In-Network: 100% covered for preventive ; diagnostic: covered as any other illness, for Cancer Clinical Trials refer to EOC/SPD Out-of-Network: Covered as any other illness; for Cancer Clinical Trials refer to ECO/SPD In Network - Diagnostic test/diagnostic treatment: 90% covered after Out of Network - Diagnostic test/diagnostic treatment: 70% covered after ; Customary after ; subject after ; subject after ; subject 100% covered 100% covered; no Out-of-Network Diagnostic and testing: $25 copay per visit, allergy injections: $5 copay per visit $100 copay; per procedure 100% covered 100% covered Outpatient physical therapy In Network - $25 copay; limited in-network review ; limited to 25 review ; limited to 25 review $25 copay; limited to 25 visits per year; additional visits available if necessary after medical review ; limited to 25 review $25 copay; per visit
Outpatient physical therapy after ; limited in-network review; subject to R&C after ; limited in-network review; subject to R&C after ; limited to 25 visits/year; combined innetwork review; subject to R&C ; benefit limited to $25/visit after ; limited in-network review; subject to R&C
Outpatient occupational therapy In Network - $25 copay; limited in-network review after ; limited in-network review; subject to R&C ; limited to 25 review after ; limited in-network review; subject to R&C ; limited to 25 review Out of Network - 60% cov. after ; limited to 25 visits/year; combined innetwork review; subject to R&C ; benefit limited to $25/visit $25 copay; limited to 25 visits per year; additional visits available if necessary after medical review ; limited to 25 review after ; limited in-network review; subject to R&C $25 copay; per visit Outpatient speech therapy In Network - $25 copay; limited in-network review after ; limited in-network review; subject to R&C ; limited to 25 review after ; limited in-network review; subject to R&C ; limited to 25 review Out of Network - 60% cov. after ; limited to 25 visits/year; combined innetwork review; subject to R&C ; benefit limited to $25/visit $25 copay; limited to 25 visits per year; additional visits available if necessary after medical review ; limited to 25 review after ; limited in-network review; subject to R&C $25 copay; per visit Office visit: Pre/postnatal In-hospital delivery services In Network - $25 copay initial visit only ; and Customary In Network - $250 copay; 80% covered thereafter; $200 services are not preauthorized ; is met; $200 penalty if nonemergency services are not preauthorized; subject to In Network - 80% covered; deductible waived after ; subject ; $200 penalty if nonemergency services are not preauthorized after ; $200 services are not preauthorized; Customary after ; subject In Network - 80% covered; after plan deductible ; $25 copay initial visit only $250 copay; per occurrence or admittance; thereafter; $200 penalty if nonemergency services are not preauthorized In Network - ; deductible waived after ; subject after ; subject 100% covered $500 copay; per admission
Newborn nursery services Pediatric exams ; and Customary preventive ; well-child visit includes hearing and eye exam through age 6 ; and Customary after ; subject preventive ; well-child visit includes hearing and eye exam through age 6 ; and Customary after ; subject preventive ; well-child visit includes hearing and eye exam through age 6 after ; subject ; well-child visit includes hearing and eye exam through age 6 after ; subject preventive ; well-child visit includes hearing and eye exam through age 6 after ; subject 100% covered for outpatient; $500 copay per inpatient admission ; well-child visits 100% covered up to 23 months Fertility services In Network only - 50% covered; $20,000 lifetime maximum for all infertility benefits combined; medical and pharmacy In Network only - 50% covered; $20,000 lifetime maximum for all infertility benefits combined; medical and pharmacy Covered at 50% member rate; for diagnosis and treatment of involuntary infertility when approved by a Plan physician In vitro fertilization Artificial insemination In Network only - 50% covered; $20,000 lifetime maximum for all infertility benefits combined; medical and pharmacy In Network only - 50% covered; office visit copay applies; $20,000 lifetime maximum for all infertility benefits combined; medical and pharmacy Covered at 50% member rate (intrauterine only); except for donor semen and donor eggs and services related to their procurement and storage Female tubal ligation In Network - Check with Plan; 100% covered under expanded preventive for women ; and Customary In Network - Check with Plan; 100% covered under expanded preventive for women ; Customary In Network - Check with Plan; 100% covered under expanded preventive for women ; subject to reasonable and Customary In Network: Check with Plan; 100% covered under expanded preventive for women In-Network: Check with Plan; 100% covered under expanded preventive for women Out-of-Network: 70% of C&R covered after 100% covered under expanded preventive for women; after appropriate counseling In Network - $75 copay In-Network: after $25 copay; outpatient; $500 copay inpatient; after appropriate counseling Male vasectomy ; and Customary ; Customary ; subject to reasonable and Customary Out-of-Network: 70% of C&R after
Hearing Exams Hearing aids In Network - $25 copay PCP; $35 copay Specialist; copay based on place of service and services performed ; and Customary In Network - 50% covered; two hearing aid devices every 36 months; $2,000 benefit maximum; both analog and digital devices after ; subject In Network - 50% covered; limited to two hearing aids every 36 months, $2,000 limit applies; both analog and digital devices after ; subject Limits ; covered under Durable Medical Equipment; limited to one hearing aid per ear every three years $25 copay PCP; $35 copay Specialist; copay based on place of service and services performed 50% covered; two standard hearing aid devices every 36 months; $2,000 benefit maximum after ; subject ; limited to two hearing aids every 36 months, both analog and digital devices Routine vision exams Regular lenses and frames Contact lenses Accidental injury to teeth Surgical removal of oral tumors, cysts an dimpacted teeth Hospital copay (Semi- Private Room, medically necessary Intensive Care or Private Room) Includes Facility billed Lab & X- ray In- or Out-of-Network: Emergency services only; check with Plan for other covered benefits Covered under Medical Surgery Benefit In Network - $250 copay per admission; then 80% covered after plan deductible; $200 services are not preauthorized ; after plan deductible; $200 services are not preauthorized; Customary Not Covered - Except for the first pair of glasses or contacts after medically necessary eye surgery In- or Out-of-Network: Emergency services only; check with Plan for other covered benefits Covered under Medical Surgery Benefit In Network - 80% covered; after plan deductible; $200 services are not preauthorized ; after plan deductible; $200 services are not preauthorized; Customary In- or Out-of-Network: Emergency services only; check with Plan for other covered benefits Covered under Medical Surgery Benefit In Network - 80% covered; after plan deductible ; In- or Out-of-Network - Emergency services only; check with Plan for other covered benefits Covered under Medical Surgery Benefit $250 copay per admission; then ; $200 services are not preauthorized In- or Out-of-Network: Emergency services only; check with Plan for other covered benefits Covered under Medical Surgery Benefit In Network - ; after plan deductible ; 100% covered; per exam as needed $1,000 allowance per aid; every 36 months Eye exams for refraction: 100% covered Not Covered Not Covered Tumors and cysts are covered if medically necessary; extractions are covered in preparation for radiation therapy; when deemed necessary by a Plan physician; no Out-of-Network $500 copay per admission Inpatient physician and surgeon services hospital copay/deductible plan deductible plan deductible after hospital copay/deductible plan deductible 100% covered after hospital copay/deductible
Emergency room (not followed by admission) In Network - $100 copay; then 80% covered after deductible is met; waived if admitted Out of Network - $100 copay; waived if admitted In Network - $25 copay Out of Network - 80% covered after Out of Network - 80% covered after ; nonemergencies subject to In-Network: $100 copay; then ; waived if admitted Out-of-Network: $100 copay for emergencies; waived if admitted $25 copay Out of Network - after $100 copay; waived if admitted $100 copay; waived if admitted $25 copay; per visit Urgent clinic visit ; and Customary after ; subject after ; subject after ; subject $50 copay; per visit; non-plan providers covered when outside the service area Ambulance services Annual prescription deductible Prescription drug Web site Prescription drug member services Prescription benefits are covered under medical deductible Prescription drug vendor Annual Rx Out-ofpocket maximum Retail generic ; subject to medical necessity ; no copay if true emergency; must be medically necessary; Customary Not applicable ; must be medically necessary ; must be medically necessary; Customary Not applicable ; must be medically necessary Out of Network - 80% covered; must be medically necessary; Customary Medical deductible applies; member pays 100% of the Rx cost until medical deductible is met In Network - ; must be medically necessary Out of Network - ; must be medically necessary; Customary Not applicable ; must be medically necessary ; must be medically necessary; Customary Medical deductible applies; member pays 100% of the Rx cost until medical deductible is met Not applicable www.mark.com www.mark.com www.mark.com www.mark.com www.mark.com www.kaiserpermanente.org 1-866-623-1438 1-866-623-1438 1-866-623-1438 1-866-623-1438 1-866-623-1438 1-800-464-4000 No No Yes No Yes Not applicable Caremark Caremark Caremark Caremark Caremark Not applicable $2,800 Individual; $5,700 Family (in-network only) In Network - $10 copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule $2,100 Individual; $4,200 Family (in-network only) In Network - $10 copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule Medical out-of-pocket maximum applies; once medical out-of-pocket maximum is met, Rx is 100% covered for the remainder of the calendar year after $3,500 Individual; $7,000 Family (in-network only) $10 copay; 30 day supply; Nonparticipating pharmacies: 50% of average whole price schedule plus charges above the schedule Medical out-of-pocket maximum applies; once medical out-of-pocket maximum is met, Rx is 100% covered for the remainder of the calendar year after $50 copay per trip Not applicable $10 for up to a 30-day supply; $30 for up to a 100-day supply; at Pharmacy; as prescribed by Plan Physician
Retail formulary brand Retail nonformulary brand Mail order generic Mail order formulary brand In Network - 80% covered; $40 minimum copay, $60 maximum copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule In Network - 60% covered; $60 minimum copay, $100 maximum copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule $20 copay; 90 day supply; must use plan mail order facility 80% covered; $80 minimum copay, $120 maximum copay; 90 day supply; must use plan mail order facility In Network - 80% covered; $40 minimum copay, $60 maximum copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule In Network - 60% covered; $60 minimum copay, $100 maximum copay; 30 day supply Out of Network - 50% of average whole price schedule plus charges above the schedule after after $20 copay; 90 day supply; 80% covered after deductible is must use plan mail order facility met 80% covered; $80 minimum copay, $120 maximum copay; 90 day supply; must use plan mail order facility 80% covered after deductible is met 80% covered; $40 minimum copay, $60 maximum copay; 30 day supply; Nonparticipating pharmacies: 50% of average whole price schedule plus charges above the schedule 60% covered; $60 minimum copay, $100 maximum copay; 30 day supply; Nonparticipating pharmacies: 50% of average whole price schedule plus charges above the schedule $20 copay; 90 day supply; must use plan mail order facility 80% covered; $80 minimum copay, $120 maximum copay; 90 day supply; must use plan mail order facility after after after deductible after deductible $35 for up to a 30-day supply; $105 for up to a 100-day supply; at Pharmacy; as prescribed by Plan Physician $35 for up to a 30-day supply; $105 for up to a 100-day supply; at Pharmacy; as prescribed by Plan Physician $10 for up to a 30-day supply; $20 for up to a 100-day supply; mail order as prescribed by Plan Physician $35 for up to a 30-day supply; $70 for up to a 100-day supply; mail order as prescribed by Plan Physician Mail order nonformulary brand 60% covered; $120 minimum copay, $200 maximum copay; 90 day supply; must use plan mail order facility 60% covered; $120 minimum copay, $200 maximum copay; 90 day supply; must use plan mail order facility 80% covered after deductible is met 60% covered; $120 minimum copay, $200 maximum copay; 90 day supply; must use plan mail order facility after deductible $35 for up to a 30-day supply; $70 for up to a 100-day supply; mail order as prescribed by Plan Physician and deemed medically necessary Oral contraceptives Check with Plan; some contraceptives 100% covered under expanded preventive for women Check with Plan; some contraceptives 100% covered under expanded preventive for women Check with Plan; some contraceptives 100% covered under expanded preventive for women Check with Plan; some contraceptives 100% covered under expanded preventive for women 100% covered as part of expanded preventive for women Fertility drugs Check with Plan Check with Plan Check with Plan Check with Plan Check with Plan Mental Health: Combined with substance abuse Mental Health: Outpatient 50% member rate copay as prescribed by Plan physician No $25 copay individual visit; $12 copay group visit; unlimited visits Mental Health: Inpatient $500 copay per admission Detox: Outpatient Detox is necessitated by the acute poisoning of the system with a substance. This acute situation is not handled on an Outpatient basis. $25 copay individual visit; $5 copay group visit; unlimited visits
Detox: Inpatient Inpatient Detox is treated as a medical condition and covered under the hospital inpatient benefit. Even if the plan does not cover the treatment of Substance Abuse, inpatient detox is covered. $500 copay per admission; $100 copay for transitional residential recovery services; mental health/chemical dependency services accrue to out-of-pocket maximum Rehab: Outpatient $25 copay individual visit; $5 copay group visit; unlimited visits Rehab: Inpatient $500 copay per admission; $100 copay for transitional residential recovery services; mental health/chemical dependency services accrue to out-of-pocket maximum In Network - $25 copay; limited to 25 visits per calendar year ; limited to 25 visits per calendar year ; limited to 25 and out-of-network $25 copay; limited to 25 visits per calendar year ; limited to 25 visits per calendar year Member discounts available through American Specialty Health network Chiropractic ; is met; limited to 25 visits per calendar year; subject to after ; limited to 25 visits per calendar year; Customary after ; limited to 25 visits/year; combined innetwork Customary ; benefit limited to $25 per visit after ; limited to 25 visits per calendar year; Customary In Network - $25 copay; limited to 25 visits per calendar year ; limited to 25 visits per calendar year ; limited to 25 visits per calendar year (combined in/out-of-network) and $30 per visit $25 copay; limited to 25 visits per calendar year ; limited to 25 visits per calendar year Member discounts available Acupuncture ; is met; limited to 25 visits per calendar year; subject to after ; limited to 25 visits per calendar year; Customary after ; limited to 25 visits per calendar year (combined in/out-of-network) and $30 per visit; subject to after ; limited to 25 visits per calendar year; Customary Heart disease management Hypertension management Diabetes management Asthma management Prenatal management Cancer management Smoking cessation program Not applicable (treatment of the disease is covered)
Weight control program except for treatment of Anorexia Nervosa or Bulimia Nervosa (See Mental Nervous Benefit) except for treatment of Anorexia Nervosa or Bulimia Nervosa (See Mental Nervous Benefit) except for treatment of Anorexia Nervosa or Bulimia Nervosa (See Mental Nervous Benefit) except for treatment of Anorexia Nervosa or Bulimia Nervosa (See Mental Nervous Benefit) except for treatment of Anorexia Nervosa or Bulimia Nervosa (See Mental Nervous Benefit)
Noncustodial home health Hospice ; limited to 100 visits per calendar year; per visit after ; limited to 100 visits per calendar year; per visit; subject to Reasonable and Customary ; as authorized by Anthem Blue Cross Case Management; limitations may after ; as authorized by Anthem Blue Cross Case Management; subject to R&C ; limitations may ; limited to 100 visits per calendar year; per visit after ; limited to 100 visits per calendar year; per visit; subject to Reasonable and Customary limit ; as authorized by Anthem Blue Cross Case Management; limitations may Out of Network - 80% covered after ded is met; as authorized by Anthem Blue Cross Case Management; subject to R&C ; limitations may ; limited to 100 visits per calendar year; per visit after ; limited to 100 visits per calendar year; per visit; subject to Reasonable and Customary as authorized by Anthem Blue Corss Case Management; limitations may Out-of-Network: 80% covered after as authorized by Anthem Blue Cross Case Management; subject to C&R ; limitations may ; limited to 100 visits per calendar year; per visit ; as authorized by Anthem Blue Cross Case Management; limitations may ; limited to 100 visits per calendar year; 100% covered; up to 100 visits per calendar year per visit after ; limited to 100 visits per calendar year; per visit; subject to Reasonable and Customary limit In-Network: after as authorized by Anthem Blue Cross Case Management; limitations may Out-of-Network: 70% covered after as authorized by Anthem Blue Cross Case Management; subject to C&R ; limitations may 100% covered when prescribed by Plan Physician Prescribed in noncustodial skilled nursing facility Durable medical equipment C&R = customary and reasonable ; limited to 240 days per calendar year; combined in-network and outof-network after ; limited to 240 days per calendar year; subject to ; Customary ; limited to 240 days per calendar year; combined in-network and outof-network after ; limited to 240 days per calendar year; subject to after ; subject ; limited to 100 days per calendar year; combined in-network and outof-network after ; limited to 100 days per calendar year; subject to ; subject to utilization review after ; subject to utilization review; subject to ; limited to 240 days per calendar year ; limited to 240 days per calendar year; combined in-network and outof-network after ; limited to 240 days per calendar year; subject to after ; subject 100% covered; up to 100 days per benefit period; when prescribed by Plan Physician 100% covered; formulary