UNDER AGE 65 HEALTH PLANS FOR PARTICIPANTS. Kern County 2019 Retiree

Transcription

1 Kern County 2019 Retiree HEALTH PLANS FOR PARTICIPANTS UNDER AGE 65 For current participating physician information, please contact each plan directly. This summary is for information purposes only. Members should review complete plan document before enrolling. If any item differs between these summaries and any plan documents, the plan document will govern.

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3 Only for participants under age 65 Share Select uses Kern Legacy s exclusive network design, based around Kern Medical as the premier hospital, along with a solid selection of other community providers. This plan is a high-deductible plan designed to generate even more savings. For many services (except preventive care and certain medications), the member pays the entire contracted rate before the deductible is met. However, these higher out of pocket costs allow premiums at low cost. If you are in good health and make good healthcare choices, you can save significantly. Annual Deductible: $2,000 Individual/ $4,000 Family Medical/Pharmacy Out of Pocket Maximum: $6,000 Individual/ $12,000 Family $10 co-pay for Primary Care Physician office visit after deductible $20 co-pay for specialist co-payment with referral after deductible $0 co-pay for PCP or Specialist for Preventative Care Visit (deductible does not apply). $15 co-pay for Urgent Care after deductible. $100 co-pay day/$500 per Hospitization at Kern Medical Center after deductible. $150 co-pay for emergency room (waived if admitted) after deductible. Outpatient Surgery: $0 co-pay at Kern Medical after deductible; $50 co-pay after deductible at contracted Surgery Centers. $10 co-pay for Chiropractic Services after deductible (maximum 20 visits per calendar year) $25 co-pay for CT/PET/MRI at Kern Medical after deductible. Preventative Generic Drugs - $10 co-pay, deductible does not apply. Kern Medical Pharmacies (Non-Specialty Drugs, up to 90 day supply) - $0 generic; $25 preferred brand; $50 non-preferred after deductible Kern Medical Pharmacies (Specialty Drugs, up to 30 day supply) - $50 generic; $90 preferred brand; $120 non-preferred after deductible Non-Kern Medical Retail (up to 30 day supply) - $5 generic; $50 preferred brand; $90 non-preferred after deductible If a retiree participant or dependent is eligible for Medicare, then Medicare is primary and Kern Legacy Share Select is secondary. For additional plan information, please visit our website at For Kern Legacy Share Select enrollment forms,

4 20% Only for participants under age 65 Network Plus features our custom local network but gives members access to a greater number of contracted providers for more options. The original Exclusive Provider Organization (EPO) network from Kern Legacy Share Select remains available on this plan, with many services at low or no cost to the member. However, Kern Legacy Network Plus adds an additional Plus benefit tier, featuring even more providers. Members pay a higher 20% coinsurance (after deductible) per Plus service used, with no change in monthly premiums. Network Plus is perfect for anyone that is looking for a quality, affordable health plan with plenty of options. $0 Deductible Premier EPO Level $10 co-pay for Primary Care Physician office visit co-payment $20 co-pay for specialist co-payment with referral $15 co-pay for Urgent Care $0/day Hospitalization co-payment at Kern Medical Outpatient Surgery: $0 co-pay at KM; $50 copay at Surgery Center $25 co-pay for CT/PET/MRI Additional PLUS Level Deductible of $250 single / $500 family Medical Out Of Pocket: $4,000 person / $8,000 family No PCPs at Plus Level No wellness visits at Plus Level 20% Coinsurance for Plus Level Specialist, initial consult is self-refer 20% Coinsurance for Plus Level contracted inpatient or out-patient hospital or surgery center Coinsurance for Plus Level contracted lab or radiology service Chiropractic EPO is $10 per visit; PPO is 20% coinsurance after deductible (maximum 20 visits per calendar year) $150 emergency room co-payment applies unless admitted. Out of Area Emergency Services must be approved by plan administrator (must call plan administrator within 48 hours or the next business day. $100/day co-pay applies to any approved non-network admission. Kern Medical (Retail and Mail Order, up to 90 day supply) - $0 generic; $20 preferred brand; $40 non-preferred. Non-Kern Medical Retail (up to 30 day supply) - $5 generic; $45 preferred brand; $65 non-preferred If a retiree participant or dependent is eligible for Medicare, then Medicare is primary and Kern Legacy Network Plus is secondary. For additional plan information, please visit our website at For Kern Legacy Network Plus enrollment forms,

5 Only for participants under age 65 New for Kern Legacy Max Choice features an affordable 20% coinsurance and low deductible, with the same Anthem Blue Cross network of providers as the County's original benefit plan, Kern Legacy Classic Choice (formerly the "Point of Service Plan ). Max Choice covers the majority of local physicians, facilities, and hospitals, giving you plenty of flexibility for your care. Anthem Blue Cross offers one of the largest provider networks in the nation, and it covers almost the entire nation. Up to 90% of providers within California are participating providers with Anthem. Medical Annual Deductible: $250 Individual / $500 Family Medical Out of Pocket Maximum: $5,000 Individual/ $10,000 Family $10 co-pay for contracted Primary Care Physician office visits after deductible $25 co-pay at Kern Medical or 20% coinsurance or for contracted Specialist visits after deductible $0 co-pay for PCP or Specialist for Preventative Care Visit (deductible does not apply). $0 co-pay for Laboratory Services after deductible $100/day Hospitalization at Kern Medical/ 20% coinsurance at other locations (maximum $2,500 per admission) after deductible $15 co-pay for Urgent Care after deductible $150 co-pay for Emergency Room Visits after deductible (waived if admitted). Prescription Deductible: $100/person Prescription Out of Pocket Maximum: $1,000 per person/ $3,000 per family Kern Medical Pharmacies (up to 90-day supply) after deductible: $0 Generic, $25 Preferred Name Brand; $50 Non-Preferred Name Brand Retail Pharmacies (Up to 30-day supply) after deductible: $5 Generic; $250 Preferred Name Brand; $90 Non-Preferred Name Brand Specialty Medications (Up to 30-day supply) after deductible: $50 Generic; $90 Preferred Name Brand; $120 Non-Preferred Name Brand If a retiree participant or dependent is eligible for Medicare, then Medicare is primary and Kern Legacy Max Choice is secondary. For additional plan information, please visit our website at For Kern Legacy Max Choice enrollment forms,

6 Only for participants under age 65 Kern Legacy Classic Choice is the same benefits as The County of Kern POS (Point of Service) Plan, simply a new name. The Kern Legacy Classic Choice offers you the same medical and prescription coverage that is available to active County employees, which includes In-Network and Out-Of-Network benefits and utilizes the Anthem Blue Cross Network of providers. Annual Deductible: $0 In-Network Benefits Medical Out of Pocket Maximum: $1,000 Individual/ $3,000 Family for In-Network Benefits Pharmacy Out of Pocket Maximum: $5,600 Individual / $10,200 Family $15 co-pay for contracted Primary Care Physician office visits $25 co-pay for contracted Specialist visits $0 co-pay for Laboratory Services $150/day Hospitalization (maximum $750/year per member) $15 co-pay for Urgent Care $75 co-pay For Emergency Room Visits (waived if admitted). World-wide emergency care as approved by plan administrator (must call plan administrator within 48 hours or the next business day) $20 co-pay Chiropractic Services (30 annual visits maximum per calendar year) Option to choose Out-Of-Network provider services with reduced benefits to 70% coverage of Usual & Customary charges after deductible of $200 per person/ $400 per family for covered services. Maximum Out of Pocket: $2,000 per person / $4,000 per Family (2 members at $2,000) Generic Drugs: $5 (30-day retail) or $10 (90-day mail order) or $0 at Kern Medical pharmacies Preferred Brand Name: $25 (30 day retail) or $50 (90 day mail order) Non-Preferred Brand Name (No Generic Available): $40 (30-day retail) or $80 (90-day mail order) Non-Preferred Brand Name (Generic Available): Non-Preferred co-pay plus the difference in the retail cost between the Brand name and the Generic drug. If a retiree participant or dependent is eligible for Medicare, then Medicare is primary and Kern Legacy Classic Choice is secondary. For additional plan information, please visit our website at For Kern Legacy Classic Choice enrollment forms,

7 Kaiser Permanente Group # Only for participants under age 65 Medical Annual Deductible: $0 Plan Out-Of-Pocket Maximum: $1,500 Member/$3,000 Family $15 per visit for most Primary Care Physician Visits $15 per visit for most Physician Specialist Visits $15 per visit for Urgent Care consultations, evaluations and treatments $15 per procedure for Outpatient Surgery and Procedures $50 per visit for Emergency Service, waived if admitted. $50 per trip for Ambulances Services No charge for Hospitalizations Services: Room and board, surgery, anesthesia, X-Rays, laboratory tests and drugs. No charge for most X-Rays and laboratory tests. 20% coinsurance per item for Durable Medical Equipment No charge for Skilled nursing facility care, up to 100 days per calendar year No charge for Home Health care, up to 100 visits per calendar year, Frame allowance of $125 on eyewear purchased from Kaiser contracted facilities every 24 months. Kaiser Pharmacies: $10 co-pay for most Generic Drugs (Up to 100-day supply) $20 co-pay for most Brand Name Drugs (Up to 100-day supply) $20 co-pay for most Specialty Drugs (Up to 30-day supply) For additional plan information, please contact: Jose Hernandez at Kaiser Permanente at (661) For Kaiser Permanente enrollment forms,

8 Only for participants under age 65 Health Net Under 65" HMO Group # 50874T Medical Annual Deductible: $0 Plan Out-Of-Pocket Maximum: $1,500 Member/$3,000 2-Members / $4,500 Family $5 co-payment for office visit (at participating provider group) No charge for x-ray and laboratory procedures No charge for durable medical equipment No charge for hospital stays (semi-private or intensive care) $35 co-payment for emergency room and $35 for urgent care facility, waived if admitted. $5 co-payment for vision and hearing exams $100 frame allowance (once every 24 months) $5 co-payment for chiropractic care (20 visits per calendar year) Retail: $5 generic $10 brand prescription co-payment (plan formulary), $35 co-pay for non-formulary drugs, up to a 30-day supply Mail order (90 day supply): $10 generic $20 brand prescription co-payment (plan formulary) $70 co-pay for non-formulary drugs Local (Kern County) providers: GEMCare Medical Group Bakersfield Family Medical Center/Heritage Physicians Network Independence Medical Group. For additional plan information, please call Health Net at (800) For Health Net Under 65 enrollment forms,