| Members eligible for Medicare must enroll in Medicare to the full extent of their eligibility. |
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| Under the Blue Cross PPO Prudent Buyer Plan, you have the greatest choice of healthcare professionals because you may receive healthcare services from any licensed healthcare professional for your covered services. Under the Prudent Buyer plan you may choose between a Blue Cross PPO provider and a non-PPO provider (a provider who does not belong to the Blue Cross PPO network). However, you may receive significant cost reductions if you visit Blue Cross PPO network healthcare professionals for covered services. When you use a non-PPO provider, you may be required to pay for the service at the time services are rendered and to submit your own claim forms to Blue Cross. |
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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 |
| 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 (2010 = $1,100) 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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| Blue Cross Plans - Retiree Rates Effective July 1, 2010 |
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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 B. |
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| PPO PLAN NON-MEDICARE MONTHLY RATES |
|
| PART CODES |
Coverage Category |
Monthly Premium Rate |
| 10 |
Member Only |
$ 847.14 |
| 11 |
Two Party |
1,456.62 |
| 12 |
Family |
1,566.40 |
|
| PPO PLAN MEDICARE MONTHLY RATES - A&B, A&B&D, B Only, B&D |
|
|
|
|
| 20 |
Member B&D |
$ 657.14 |
| 20a |
Member B Only |
702.14 |
| 21 |
2 Party: Member B&D; Spouse A&B&D |
1,052.43 |
| 21a |
2 Party: Member B&D; Spouse A&B |
1,078.48 |
| 21b |
2 Party: Member B; Spouse A&B&D |
1,097.43 |
| 21c |
2 Party: Member B; Spouse A&B |
1,181.37 |
| 22 |
2 Party: Member None; Spouse A&B&D |
1,242.43 |
| 22a |
2 Party: Member None; Spouse A&B |
1,268.48 |
| 23 |
2 Party: Member B&D; Spouse B&D |
1,156.63 |
| 23a |
2 Party: Member B&D; Spouse B |
1,182.68 |
| 23b |
2 Party: Member B; Spouse B&D |
1,201.63 |
| 23c |
2 Party: Member B; Spouse B |
1,227.68 |
| 24 |
2 Party: Member None; Spouse B&D |
1,346.63 |
| 24a |
2 Party: Member None; Spouse B |
1,372.68 |
| 25 |
2 Party: Member B&D; Spouse None |
1,266.62 |
| 25a |
2 Party: Member B; Spouse None |
1,311.62 |
| 26 |
3 Party: Member B&D; Spouse None; Deps None |
1,376.40 |
| 26a |
3 Party: Member B; Spouse None; Deps None |
1,421.40 |
| 27 |
3 Party: Member None; Spouse A&B&D; Deps None |
1,352.21 |
| 27a |
3 Party: Member None; Spouse A&B; Deps None |
1,378.26 |
| 28 |
2 Party: Member B&D; Spouse A&D |
1,136.37 |
| 29 |
3 Party: Member None; Spouse None; Deps A&B&D |
1,366.13 |
| 29a |
3 Party: Member None; Spouse None; Deps A&B |
1,390.49 |
| 30 |
Member Only A&B&D |
477.14 |
| 30a |
Member Only A&B |
522.14 |
| 31 |
2 Party: Member A&B&D; Spouse None |
1,086.62 |
| 31a |
2 Party: Member A&B; Spouse None |
1,131.62 |
| 31b |
2 Party: Member A&B&D; Spouse A&D |
956.37 |
| 31c |
2 Party: Member A&B&D; Spouse A |
982.42 |
| 32 |
2 Party: Member A&B&D; Spouse B&D |
976.63 |
| 32a |
2 Party: Member A&B&D; Spouse B |
1,002.68 |
| 32b |
2 Party: Member A&B; Spouse B&D |
1,021.63 |
| 32c |
2 Party: Member A&B; Spouse B |
1,047.68 |
| 33 |
2 Party: Both A&B&D |
872.43 |
| 33a |
2 Party: Member A&B; Spouse A&B&D |
917.43 |
| 33b |
2 Party: Member A&B&D; Spouse A&B |
898.48 |
| 33c |
2 Party: Both A&B |
943.48 |
| 33d |
2 Party: Member A&D; Spouse A&B&D |
1,017.43 |
| 34 |
3 Party: Member A&B&D; Spouse None; Deps None |
1,196.40 |
| 34a |
3 Party: Member A&B; Spouse None; Deps None |
1,241.40 |
| 80 |
3 Party: Member A&B&D; Spouse None; Deps A&B&D |
996.13 |
| 35 |
3 Party: Member A&B&D; Spouse A&B&D; Deps None |
982.21 |
| 35a |
3 Party: Member A&B&D; Spouse A&B; Deps None |
1,008.26 |
| 35b |
3 Party: Member A&B; Spouse A&B&D; Deps None |
1,027.21 |
| 35c |
3 Party: Member A&B; Spouse A&B; Deps None |
1,053.26 |
| 35d |
3 Party: Member A&B&D; Spouse A&B&D; Deps A&B&D |
781.94 |
| 36 |
3 Party: Member None; Spouse A&B&D; Deps A&B&D |
1,151.94 |
| 36a |
3 Party: Member None; Spouse A&B&D; Deps A&B |
1,176.30 |
| 36b |
3 Party: Member None; Spouse A&B; Deps A&B&D |
1,177.99 |
| 36c |
3 Party: Member None; Spouse A&B; Deps A&B |
1,202.35 |
|
|
|
|
| PPO PLAN MEDICARE MONTHLY RATES - A Only, A&D |
|
| 37 |
Member A&D |
$ 622.14 |
| 37a |
Member A Only |
667.14 |
| 38 |
Two Party: Both A&D |
1,101.37 |
| 38a |
Two Party: Member A&D; Spouse A Only |
1,127.42 |
| 38b |
Two Party: Member A Only; Spouse A&D |
1,146.37 |
| 38c |
Two Party: Both A Only |
1,172.42 |
| 38d |
Two Party: Member None; Spouse A Only |
1,352.42 |
| 38e |
Two Party: Member None; Spouse A&D |
1,326.37 |
| 38f |
Two Party: Member A Only; Spouse None |
1,276.62 |
| 38g |
Two Party: Member A&D; Spouse None |
1,231.62 |
| 39 |
3 Party: Member A&D; Spouse A&D; Deps A&D |
1,089.36 |
| 39a |
3 Party: Member A&D; Spouse None; Deps None |
1,341.40 |
| 39b |
3 Party: Member A Only; Spouse A Only; Deps None |
1,282.20 |
| 39c |
3 Party: Member A&D; Spouse A Only; Deps None |
1,237.20 |
| 39d |
3 Party: Member A Only; Spouse A&D; Deps None |
1,256.15 |
| 39e |
3 Party: Member A&D; Spouse A&D; Deps None |
1,211.15 |
| 39f |
3 Party: Member A Only; Spouse None; Deps A Only |
1,288.97 |
| 39g |
3 Party: Member A&D; Spouse None; Deps A Only |
1,243.97 |
| 39h |
3 Party: Member A Only; Spouse None; Deps A&D |
1,264.61 |
| 39i |
3 Party: Member A&D; Spouse None; Deps A&D |
1,219.61 |
| 39j |
3 Party: Member None; Spouse A Only; Deps None |
1,462.20 |
| 39k |
3 Party: Member None; Spouse A&D; Deps None |
1,436.15 |
| 39l |
3 Party: Member None; Spouse A Only; Deps A Only |
1,364.77 |
| 39m |
3 Party: Member None; Spouse A&D; Deps A Only |
1,338.72 |
| 39n |
3 Party: Member None; Spouse A Only; Deps A&D |
1,340.41 |
| 39o |
3 Party: Member None; Spouse A&D; Deps A&D |
1,314.36 |
| 39p |
3 Party: Member None; Spouse None; Deps A Only |
1,468.97 |
| 39q |
3 Party: Member None; Spouse None; Deps A&D |
1,444.61 |
| 39r |
3 Party: Member A Only; Spouse None; Deps None |
1,386.40 |
|
|
|
|
|
| PPO PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/10 |
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|
|
|
| |
PPO (PRUDENT BUYER) PLAN |
| CALENDAR YEAR DEDUCTIBLE |
$250 per individual / $500 maximum per family
(if you, or a covered family member, are in enrolled in
Medicare A and/or B, the deductible will be waived) |
| OUT OF POCKET MAXIMUM |
$1,500 per individual In-network; and
$1,500 per individual Out-of-Network
(excludes deductible & co-payments) |
| LIFETIME MAXIMUM |
$5,000,000 per covered person |
| |
| HOSPITAL SERVICES |
| |
| EMERGENCY ROOM |
$75 co-pay; waived if admitted
(Co-pay is in addition to the deductible) |
| URGENT CARE VISITS |
For Visits at an urgent care facility:
90% In-Network (1) / 70% Out-of-Network (2) |
| INPATIENT (Room, Board and Support Services) |
90% In-Network (1) / 70% Out-of-Network (2)
(Failure to obtain pre-authorization of services will result in a 20% penalty) |
| INPATIENT MATERNITY CARE |
90% In-Network (1) / 70% Out-of-Network (2) |
| |
| PHYSICIAN SERVICES |
|
| OFFICE VISITS |
90% In-Network (1) / 70% Out-of-Network (2) |
| PHYSICAL THERAPY, PHYSICAL MEDICINE, OCCUPATIONAL THERAPY CHIROPRACTIC SERVICES (limited to 24 visits/cal yr) |
90% In-Network (1) / 70% Out-of-Network (2)
(Out-of-Network Services are limited
to a maximum benefit of $25 per visit) |
| ACUPUNCTURE (limited to 24 visits/cal yr) |
90% In-Network (1) / 70% Out-of-Network (2)
(Services are limited to a maximum benefit of $30 per visit) |
| SPEECH THERAPY (outpatient speech therapy following injury or organic disease) |
90% In-Network / 90% Out-of-Network |
| |
| HEALTH MAINTENANCE |
| |
| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBER AND DEPENDENTS |
At In-Network Providers Only
$25 co-payment; 100% up to $250 calendar year maximum.
Not subject to the deductible. |
| WELL WOMAN CARE |
90% In-Network (1) / 70% Out-of-Network (2)
1 routine gynecology physical exam per calendar year.
Includes breast and pelvic exams, mammogram & pap smears. |
| WELL BABY AND WELL CHILD CARE, UP TO AGE 19 |
90% In-Network (1) / 70% Out-of-Network (2) |
| |
| CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE |
| |
| INPATIENT |
90% Par1 70% Non-Par2 |
| OUTPATIENT |
90% Par1 70% Non-Par2 |
| |
| MENTAL OR NERVOUS DISORDER |
| |
| INPATIENT |
90% Par1 70% Non-Par2 |
| OUTPATIENT |
90% Par1 70% Non-Par2 |
| |
| OTHER COVERED EXPENSES |
| |
| HEARING AID BENEFIT |
90% In-Network (1) / 80% Out-of-Network (2)
up to $1,500 for both ears every 3 years;
deductible waived |
| PRESCRIPTION DRUGS - RETAIL PHARMACY (30-day supply) |
$15 for Generic, $25 for Brand (3)
20% (to a max. of $100 copay per prescription) for injectables (4) |
| MAIL ORDER (90-day supply) |
$15 for Generic, $25 for Brand
20% (to a max. of $100 copay per prescription) for injectables (4) |
| VISION CARE |
$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP). |
| |
| 1. Par (or In-Network) refers to Participating Blue Cross Provider. For Outside California, it is a Blue Cross/Blue Shield Provider. There are substantial savings when you use a Par Provider. Subject to the deductible. |
|
| 2. Non-Par (or Out-of-Network) is a Non-Participating Provider. Out-of-Pocket benefits are higher when you choose to use a Non-Par Provider. Subject to the deductible. |
|
| 3. Participating Blue Cross Pharmacy: When a generic equivalent is available, you will pay the brand co-pay plus the difference of prescription drug covered expense between the generic and the brand name drug, if you are not enrolled in Medicare Part D. |
|
| 4. The 20% co-pay does not apply to insulin. The standard co-pays of $15 Generic and $25 Brand Names apply to insulin. |
|
| 5. Professional services that may be available from Blue Cross PPO providers, but would usually be available from providers whose specialties are not represented in the Blue Cross PPO network, are payable at the higher reimbursement level of the plan. |
|
| 6. 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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| 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. |
