| Under the Blue Cross HMO (CaliforniaCare) plan you must select a primary care physician for each enrolled family member from a medical group or independent practice association (IPA) under the plan's network. Blue Cross has contracted with a network of physicians, hospitals, and other health care providers to offer health care services to those covered under the HMO plan. The network of physicians consists of primary care physicians which include family practice, internal medicine, pediatrics, general practice or obstetrics/gynecology. You must receive services only from your primary care physician in order to receive coverage, except in an emergency or if you use the Plus coverage under the Plan as described in the following Plan Benefit Overview. You must receive a referral from your primary care physician to see a specialist in order to receive coverage unless you use the Plus coverage under the Plan. |
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| HMO PLAN RATES - MEMBER COST PER PAY PERIOD - EFFECTIVE 7/1/11 |
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| 92 |
Member Only |
$0.00 |
| 93 |
Two Party |
$0.00 |
| 94 |
Family |
$0.00 |
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| HMO PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/11 |
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| CALENDAR YEAR DEDUCTIBLE |
NA |
| OUT-OF-POCKET MAXIMUM |
Co-pay maximum1 $500 per member $1,500 per family |
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| Note: The Out-of-Pocket Maximum does not apply to infertility treatment under the CalifornaCare “Plus” Plan. |
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| HOSPITAL SERVICES |
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| EMERGENCY ROOM |
$75 co-pay; waived if admitted |
| URGENT CARE VISITS |
For visits at an assigned medical group $10 co-pay |
| INPATIENT (Room, Board and Support Services) |
100% Covered |
| INPATIENT MATERNITY CARE |
100% Covered |
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| PHYSICIAN SERVICES |
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| OFFICE VISITS |
$10 co-pay |
| Physical Therapy, Physical Medicine, Occupational Therapy, Chiropractic Services (limited to 60 days of care after illness or injury; additional visits available when approved by the medical group) |
$10 co-pay |
| Speech Therapy (outpatient speech therapy following injury or organic disease) |
$10 co-pay |
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| HEALTH MAINTENANCE |
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| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBERS AND DEPENDENTS |
100% Covered |
| WELL WOMAN CARE |
100% Covered |
| WELL BABY AND WELL CHILD CARE |
100% Covered |
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| MENTAL HEALTH / SUBSTANCE ABUSE |
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| INPATIENT HOSPITAL |
100% Covered |
| OUTPATIENT PHYSICIAN SERVICES |
$10 co-pay |
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| OTHER COVERED EXPENSES |
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| HEARING AID BENEFIT |
No Charge (limited to one aid per ear, every 36 months) |
| PRESCRIPTION DRUGS - RETAIL PHARMACY (30 day supply) |
$10 for Generic - $15 for Brand
20% (to a max. of $100 copay per prescription) for injectables2 |
| PRESCRIPTION DRUGS - MAIL ORDER (90-day supply) |
$10 for Mail Order
20% (to a max. of $100 copay per prescription) for injectables2 |
| VISION CARE |
$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP). |
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| 1. Co-pay maximum does not apply to infertility treatment under the CaliforniaCare "Plus" Plan. |
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| 2 The 20% co-pay does not apply to insulin. The standard co-pays of 10% generic and 15% brand name apply to insulin. |
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| * 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, your cost will be less. |
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| Deductibles, co-payments and benefit limits for “Plus” benefits are shown below. They are treated entirely separately from the CaliforniaCare HMO benefit summarized above. Note: See the section “Your Plus Benefits” in the Evidence of Coverage for more details. |
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| · Calendar Year Deductibles: Member = $100/Family = $300 |
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| · Co-Payments: After you have met your calendar year deductible, the percentage for covered expense, are as follows: In-Network1 = 80% and Out-of-Network2 = 60% |
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| · Calendar Year Limits: Benefit Maximum is $1,000. After the Calendar Year Limit is reached, you are responsible for any expense for services received outside of the CaliforniaCare HMO network providers. |
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| The foregoing brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Blue Cross contract. Please refer to the Blue Cross evidence of coverage for details on benefits. |
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| 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. |
