| Under the Blue Cross HMO (CaliforniaCare) plan you must select a primary care physician for each enrolled family member for 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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| Medicare Part D |
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| In 2003, the Federal Government voted to expand Medicare coverage to include Pharmacy coverage known as Medicare Part D. This benefit became effective January 1, 2006. As a Member of LAPRA, you and your covered dependents already have pharmacy benefits provided by LAPRA through Blue Cross and Kaiser that are much better than those that are available through Medicare Part D. Consequently, the Federal Government has encouraged plans, such as ours, to continue to provide pharmacy coverage. If you or any of your covered dependents are eligible for, and enroll in, Medicare Part D through a plan other than the LAPRA Blue Cross or Kaiser plans, your premium costs may be higher. |
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| Medicare Definitions |
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| Part A: Pays for inpatient hospital, skilled nursing facility, and some home health care. For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days. |
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| Part B: Covers Medicare eligible physician services, outpatient hospital services, certain home health services, and durable medical equipment. |
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| Part D: This is the prescription drug benefit that became available to Medicare Part A and/or Part B beneficiaries beginning January 1, 2006. Eligible individuals include all retirees and dependents eligible for Medicare Part A or enrolled in Part B. |
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| HMO PLAN NON-MEDICARE MONTHLY RATES - EFFECTIVE 7/1/11 |
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| Note: City Subsidy varies and is determined by retirement date, age and years of service. |
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| Note: If you or any of your covered dependents are eligible for, and enroll in, Medicare Part D through a plan other than the LAPRA Blue Cross plans, your premium costs may be higher. You are eligible to enroll in Medicare Part D through the LAPRA Blue Cross plans if you are enrolled in Medicare Parts A and/or Part B. |
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| PART CODES |
Coverage Category |
Monthly Premium Rate |
| 10 |
Member Only |
521.76 |
| 11 |
Two Party |
990.16 |
| 12 |
Family |
1,172.98 |
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| HMO PLAN MEDICARE MONTHLY RATES (CALIFORNIA RESIDENTS) - A&B, A&B&D, B Only, B&D |
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| 20 |
Member B&D |
461.76 |
| 20a |
Member B Only |
481.76 |
| 21 |
2 Party: Member B&D; Spouse A&B&D |
862.27 |
| 21a |
2 Party: Member B&D; Spouse A&B |
872.71 |
| 21b |
2 Party: Member B; Spouse A&B&D |
882.27 |
| 21c |
2 Party: Member B; Spouse A&B |
892.71 |
| 22 |
2 Party: Member None; Spouse A&B&D |
922.27 |
| 22a |
2 Party: Member None; Spouse A&B |
932.71 |
| 23 |
2 Party: Member B&D; Spouse B&D |
898.83 |
| 23a |
2 Party: Member B&D; Spouse B |
909.27 |
| 23b |
2 Party: Member B; Spouse B&D |
918.83 |
| 23c |
2 Party: Member B; Spouse B |
929.27 |
| 24 |
2 Party: Member None; Spouse B&D |
958.83 |
| 24a |
2 Party: Member None; Spouse B |
969.27 |
| 25 |
2 Party: Member B&D; Spouse None |
930.16 |
| 25a |
2 Party: Member B; Spouse None |
950.16 |
| 26 |
3 Party: Member B&D; Spouse None; Deps None |
1,112.98 |
| 26a |
3 Party: Member B; Spouse None; Deps None |
1,132.98 |
| 27 |
3 Party: Member None; Spouse A&B&D; Deps None |
1,105.09 |
| 27a |
3 Party: Member None; Spouse A&B; Deps None |
1,115.53 |
| 28 |
2 Party: Member B&D; Spouse A&D |
883.16 |
| 29 |
3 Party: Member None; Spouse None; Deps A&B&D |
1,115.37 |
| 29a |
3 Party: Member None; Spouse None; Deps A&B |
1,124.23 |
| 30 |
Member Only A&B&D |
391.76 |
| 30a |
Member Only A&B |
411.76 |
| 31 |
2 Party: Member A&B&D; Spouse None |
860.16 |
| 31a |
2 Party: Member A&B; Spouse None |
880.16 |
| 31b |
2 Party: Member A&B&D; Spouse A&D |
813.16 |
| 31c |
2 Party: Member A&B&D; Spouse A |
823.60 |
| 31d |
2 Party: Member A&B; Spouse A&D |
833.16 |
| 32 |
2 Party: Member A&B&D; Spouse B&D |
828.83 |
| 32a |
2 Party: Member A&B&D; Spouse B |
839.27 |
| 32b |
2 Party: Member A&B; Spouse B&D |
848.83 |
| 32c |
2 Party: Member A&B; Spouse B |
859.27 |
| 33 |
2 Party: Both A&B&D |
792.27 |
| 33a |
2 Party: Member A&B; Spouse A&B&D |
812.27 |
| 33b |
2 Party: Member A&B&D; Spouse A&B |
802.71 |
| 33c |
2 Party: Both A&B |
822.71 |
| 33d |
2 Party: Member A&D; Spouse A&B&D |
832.27 |
| 34 |
3 Party: Member A&B&D; Spouse None; Deps None |
1,042.98 |
| 34a |
3 Party: Member A&B; Spouse None; Deps None |
1,062.98 |
| 80 |
3 Party: Member A&B&D; Spouse None; Deps A&B&D |
985.37 |
| 35 |
3 Party: Member A&B&D; Spouse A&B&D; Deps None |
975.09 |
| 35a |
3 Party: Member A&B&D; Spouse A&B; Deps None |
995.98 |
| 35b |
3 Party: Member A&B; Spouse A&B&D; Deps None |
995.09 |
| 35c |
3 Party: Member A&B; Spouse A&B; Deps None |
1,005.53 |
| 35d |
3 Party: Member A&B&D; Spouse A&B&D; Deps A&B&D |
917.48 |
| 35e |
3 Party: Member A&B&D; Spouse A&D; Deps None |
985.53 |
| 35f |
3 Party: Member A&B&D; Spouse A; Deps None |
1,006.42 |
| 35g |
3 Party: Member A&B; Spouse A&D; Deps None |
1,015.98 |
| 36 |
3 Party: Member None; Spouse A&B&D; Deps A&B&D |
1,047.48 |
| 36a |
3 Party: Member None; Spouse A&B&D; Deps A&B |
1,056.34 |
| 36b |
3 Party: Member None; Spouse A&B; Deps A&B&D |
1,057.92 |
| 36c |
3 Party: Member None; Spouse A&B; Deps A&B |
1,066.78 |
| 37 |
Member A&D |
431.76 |
| 37a |
Member A Only |
451.76 |
| 38 |
Two Party: Both A&D |
853.16 |
| 38a |
Two Party: Member A&D; Spouse A Only |
863.60 |
| 38b |
Two Party: Member A Only; Spouse A&D |
873.16 |
| 38c |
Two Party: Both A Only |
883.60 |
| 38d |
Two Party: Member None; Spouse A Only |
953.60 |
| 38e |
Two Party: Member None; Spouse A&D |
943.16 |
| 38f |
Two Party: Member A Only; Spouse None |
920.16 |
| 38g |
Two Party: Member A&D; Spouse None |
900.16 |
| 39 |
3 Party: Member A&D; Spouse A&D; Deps A&D |
996.10 |
| 39a |
3 Party: Member A&D; Spouse None; Deps None |
1,082.98 |
| 39b |
3 Party: Member A Only; Spouse A Only; Deps None |
1,066.42 |
| 39c |
3 Party: Member A&D; Spouse A Only; Deps None |
1,046.42 |
| 39d |
3 Party: Member A Only; Spouse A&D; Deps None |
1,055.98 |
| 39e |
3 Party: Member A&D; Spouse A&D; Deps None |
1,035.98 |
| 39f |
3 Party: Member A Only; Spouse None; Deps A Only |
1,071.96 |
| 39g |
3 Party: Member A&D; Spouse None; Deps A Only |
1,051.96 |
| 39h |
3 Party: Member A Only; Spouse None; Deps A&D |
1,063.10 |
| 39i |
3 Party: Member A&D; Spouse None; Deps A&D |
1,043.10 |
| 39j |
3 Party: Member None; Spouse A Only; Deps None |
1,136.42 |
| 39k |
3 Party: Member None; Spouse A&D; Deps None |
1,125.98 |
| 39l |
3 Party: Member None; Spouse A Only; Deps A Only |
1,105.40 |
| 39m |
3 Party: Member None; Spouse A&D; Deps A Only |
1,094.96 |
| 39n |
3 Party: Member None; Spouse A Only; Deps A&D |
1,096.54 |
| 39o |
3 Party: Member None; Spouse A&D; Deps A&D |
1,086.10 |
| 39p |
3 Party: Member None; Spouse None; Deps A Only |
1,141.96 |
| 39q |
3 Party: Member None; Spouse None; Deps A&D |
1,133.10 |
| 39r |
3 Party: Member A Only; Spouse None; Deps None |
1,102.98 |
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| CALIFORNIA CARE HMO "PLUS" PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/11 |
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| CALENDAR YEAR DEDUCTIBLE |
N/A |
| OUT OF POCKET MAXIMUM |
$500 for member1,$1500 per family |
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| HOSPITAL SERVICES |
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| EMERGENCY ROOM**(Co-pay is in addition to deductible) |
$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 injectables)2 |
| PRESCRIPTION DRUGS - MAIL ORDER (90 day supply) |
$10 for Mail Order -
20% (to a max. of $100 copay per prescription for injectables)2 |
| 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-pay of $10 generic and $15 brand apply to insulin. |
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| 3. For those who have assigned medicare Part D coverage to Blue Cross: After a member has incured $3,600 in out-of-pocket expenses, the member will pay $2.00 for generic drugs and $5.00 for brand drugs |
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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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| Note: Covered services for the treatment of severe mental disorders will not be subject to any limitations applicable to mental or nervous disorders. Such services will be subject to all other terms, conditions, limitations and exclusions, including applicable Medical Benefit Maximums. |
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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. |
