| Members eligible for Medicare must enroll in Medicare to the full extent of their eligibility. |
|
| Prudent Buyer is for members whose primary residence is within the State of California. Blue Card program is for members who reside outside California and who are not covered by Medicare. Fee-for-Service plan is for members who reside outside of California and are covered by Medicare. |
|
| Under the Blue Cross PPO Prudent Buyer, Blue Card and Fee-For-Service Plans, 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 and Blue Card plans, 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. |
| Medicare Part D |
| 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. |
|
| 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 (2009 = $1,068) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days. |
|
| Part B: Covers Medicare eligible physician services, outpatient hospital services, certain home health services, and durable medical equipment. |
|
| 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. |
|
| Blue Cross Plans - Retiree Rates Effective July 1, 2009 |
|
| Note: City Subsidy varies and is determined by retirement date, age and years of service. |
|
| 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. |
| PPO PLAN NON-MEDICARE MONTHLY RATES (CALIFORNIA RESIDENTS) |
| Office Use Only |
Coverage Category |
Monthly Premium Rate |
| 10 |
Member Only |
$795.58 |
| 11 |
Two Party |
$1,369.57 |
| 12 |
Family |
$1,474.35 |
| PPO PLAN MEDICARE MONTHLY RATES (CALIFORNIA RESIDENTS) - A&B, A&B&D, B Only, B&D |
| 20 |
Member B&D |
$564.38 |
| 20a |
Member B Only |
$613.18 |
| 21 |
2 Party: Member B&D; Spouse A&B&D |
$924.63 |
| 21a |
2 Party: Member B&D; Spouse A&B |
$973.31 |
| 21b |
2 Party: Member B; Spouse A&B&D |
$973.31 |
| 21c |
2 Party: Member B; Spouse A&B |
$1,019.11 |
| 22 |
2 Party: Member None; Spouse A&B&D |
$1,081.19 |
| 22a |
2 Party: Member None; Spouse A&B |
$1,145.94 |
| 23 |
2 Party: Member B&D; Spouse B&D |
$996.44 |
| 23a |
2 Party: Member B&D; Spouse B |
$1,042.23 |
| 23b |
2 Party: Member B; Spouse B&D |
$1,042.23 |
| 23c |
2 Party: Member B; Spouse B |
$1,095.93 |
| 24 |
2 Party: Member None; Spouse B&D |
$1,210.02 |
| 24a |
2 Party: Member None; Spouse B |
$1,271.91 |
| 25 |
2 Party: Member B&D; Spouse None |
$1,210.02 |
| 25a |
2 Party: Member B; Spouse None |
$1,271.91 |
| 26 |
3 Party: Member B&D; Spouse None; Deps None |
$1,567.29 |
| 26a |
3 Party: Member B; Spouse None; Deps None |
$1,616.08 |
| 27 |
3 Party: Member None; Spouse A&B&D; Deps None |
$1,441.48 |
| 27a |
3 Party: Member None; Spouse A&B; Deps None |
$1,490.27 |
| 28 |
2 Party: Member B&D; Spouse A&D |
$998.35 |
| 29 |
3 Party: Member None; Spouse None; Deps A&B&D |
$1,456.07 |
| 29a |
3 Party: Member None; Spouse None; Deps A&B |
$1,504.85 |
| 30 |
Member Only A&B&D |
$404.63 |
| 30a |
Member Only A&B |
$462.10 |
| 31 |
2 Party: Member A&B&D; Spouse None |
$1,051.52 |
| 31a |
2 Party: Member A&B; Spouse None |
$1,145.94 |
| 31b |
2 Party: Member A&B&D; Spouse A&D |
$966.51 |
| 31c |
2 Party: Member A&B&D; Spouse A |
$1,015.30 |
| 32 |
2 Party: Member A&B&D; Spouse B&D |
$918.83 |
| 32a |
2 Party: Member A&B&D; Spouse B |
$973.43 |
| 32b |
2 Party: Member A&B; Spouse B&D |
$973.43 |
| 32c |
2 Party: Member A&B; Spouse B |
$1,022.21 |
| 33 |
2 Party: Both A&B&D |
$738.43 |
| 33a |
2 Party: Member A&B; Spouse A&B&D |
$781.87 |
| 33b |
2 Party: Member A&B&D; Spouse A&B |
$781.87 |
| 33c |
2 Party: Both A&B |
$830.66 |
| 33d |
2 Party: Member A&D; Spouse A&B&D |
$966.51 |
| 34 |
3 Party: Member A&B&D; Spouse None; Deps None |
$1,365.11 |
| 34a |
3 Party: Member A&B; Spouse None; Deps None |
$1,451.81 |
| 80 |
3 Party: Member A&B&D; Spouse None; Deps A&B&D |
$1,067.68 |
| 35 |
3 Party: Member A&B&D; Spouse A&B&D; Deps None |
$1,067.68 |
| 35a |
3 Party: Member A&B&D; Spouse A&B; Deps None |
$1,131.37 |
| 35b |
3 Party: Member A&B; Spouse A&B&D; Deps None |
$1,131.37 |
| 35c |
3 Party: Member A&B; Spouse A&B; Deps None |
$1,180.16 |
| 36 |
3 Party: Member None; Spouse A&B&D; Deps A&B&D |
$1,082.59 |
| 36a |
3 Party: Member None; Spouse A&B&D; Deps A&B |
$1,131.37 |
| 36b |
3 Party: Member None; Spouse A&B; Deps A&B&D |
$1,131.37 |
| 36c |
3 Party: Member None; Spouse A&B; Deps A&B |
$1,180.16 |
| PPO PLAN MEDICARE MONTHLY RATES (CALIFORNIA RESIDENTS) - A Only, A&D |
| 37 |
Member A&D |
$554.25 |
| 37a |
Member A Only |
$603.04 |
| 38 |
Two Party: Both A&D |
$960.71 |
| 38a |
Two Party: Member A&D; Spouse A Only |
$1,009.49 |
| 38b |
Two Party: Member A Only; Spouse A&D |
$1,009.49 |
| 38c |
Two Party: Both A Only |
$1,058.27 |
| 38d |
Two Party: Member None; Spouse A Only |
$1,254.90 |
| 38e |
Two Party: Member None; Spouse A&D |
$1,206.10 |
| 38f |
Two Party: Member A Only; Spouse None |
$1,254.90 |
| 38g |
Two Party: Member A&D; Spouse None |
$1,206.10 |
| 39 |
3 Party: Member A&D; Spouse A&D; Deps A&D |
$834.44 |
| 39a |
3 Party: Member A&D; Spouse None; Deps None |
$1,325.25 |
| 39b |
3 Party: Member A Only; Spouse A Only; Deps None |
$1,177.43 |
| 39c |
3 Party: Member A&D; Spouse A Only; Deps None |
$1,128.63 |
| 39d |
3 Party: Member A Only; Spouse A&D; Deps None |
$1,128.63 |
| 39e |
3 Party: Member A&D; Spouse A&D; Deps None |
$1,079.84 |
| 39f |
3 Party: Member A Only; Spouse None; Deps A Only |
$1,177.43 |
| 39g |
3 Party: Member A&D; Spouse None; Deps A Only |
$1,128.63 |
| 39h |
3 Party: Member A Only; Spouse None; Deps A&D |
$1,128.63 |
| 39i |
3 Party: Member A&D; Spouse None; Deps A&D |
$1,079.84 |
| 39j |
3 Party: Member None; Spouse A Only; Deps None |
$1,374.04 |
| 39k |
3 Party: Member None; Spouse A&D; Deps None |
$1,325.25 |
| 39l |
3 Party: Member None; Spouse A Only; Deps A Only |
$1,177.43 |
| 39m |
3 Party: Member None; Spouse A&D; Deps A Only |
$1,128.63 |
| 39n |
3 Party: Member None; Spouse A Only; Deps A&D |
$1,128.63 |
| 39o |
3 Party: Member None; Spouse A&D; Deps A&D |
$1,079.84 |
| 39p |
3 Party: Member None; Spouse None; Deps A Only |
$1,374.04 |
| 39q |
3 Party: Member None; Spouse None; Deps A&D |
$1,325.25 |
| 39r |
3 Party: Member A Only; Spouse None; Deps None |
$1,374.04 |
| FEE-FOR-SERVICE PLAN MEDICARE MONTHLY RATES (NON-CALIFORNIA RESIDENTS) - A&B, A&B&D, B Only, B&D |
| 50 |
Member B&D |
$566.80 |
| 50a |
Member B Only |
$615.60 |
| 51 |
2 Party: Member B&D; Spouse A&B&D |
$928.54 |
| 51a |
2 Party: Member B&D; Spouse A&B |
$977.72 |
| 51b |
2 Party: Member B; Spouse A&B&D |
$977.72 |
| 51c |
2 Party: Member B; Spouse A&B |
$1,026.53 |
| 52 |
2 Party: Member None; Spouse A&B&D |
$1,114.14 |
| 52a |
2 Party: Member None; Spouse A&B |
$1,161.42 |
| 53 |
2 Party: Member B&D; Spouse B&D |
$1,002.66 |
| 53a |
2 Party: Member B&D; Spouse B |
$1,051.46 |
| 53b |
2 Party: Member B; Spouse B&D |
$1,051.46 |
| 53c |
2 Party: Member B; Spouse B |
$1,100.24 |
| 54 |
2 Party: Member None; Spouse B&D |
$1,230.05 |
| 54a |
2 Party: Member None; Spouse B |
$1,296.94 |
| 55 |
2 Party: Member B&D; Spouse None |
$1,230.05 |
| 55a |
2 Party: Member B; Spouse None |
$1,296.94 |
| 56 |
3 Party: Member B&D; Spouse None; Deps None |
$1,573.64 |
| 56a |
3 Party: Member B; Spouse None; Deps None |
$1,622.44 |
| 57 |
3 Party: Member None; Spouse A&B&D; Deps None |
$1,447.32 |
| 57a |
3 Party: Member None; Spouse A&B; Deps None |
$1,496.12 |
| 60 |
Member Only A&B&D |
$416.65 |
| 60a |
Member Only A&B |
$492.91 |
| 61 |
2 Party: Member A&B&D; Spouse None |
$1,085.79 |
| 61a |
2 Party: Member A&B; Spouse None |
$1,147.92 |
| 61c |
2 Party: Member A&B&D; Spouse A |
$986.84 |
| 61d |
2 Party: Member A&B&D; Spouse A&D |
$941.26 |
| 62 |
2 Party: Member A&B&D; Spouse B&D |
$928.65 |
| 62a |
2 Party: Member A&B&D; Spouse B |
$977.43 |
| 62b |
2 Party: Member A&B; Spouse B&D |
$977.43 |
| 62c |
2 Party: Member A&B; Spouse B |
$1,026.23 |
| 63 |
2 Party: Both A&B&D |
$748.26 |
| 63a |
2 Party: Member A&B; Spouse A&B&D |
$792.17 |
| 63b |
2 Party: Member A&B&D; Spouse A&B |
$792.17 |
| 63c |
2 Party: Both A&B |
$841.41 |
| 64 |
3 Party: Member A&B&D; Spouse None; Deps None |
$1,427.42 |
| 64a |
3 Party: Member A&B; Spouse None; Deps None |
$1,476.21 |
| 65 |
3 Party: Member A&B&D; Spouse A&B&D; Deps None |
$1,087.20 |
| 65a |
3 Party: Member A&B&D; Spouse A&B; Deps None |
$1,135.97 |
| 65b |
3 Party: Member A&B; Spouse A&B&D; Deps None |
$1,135.97 |
| 65c |
3 Party: Member A&B; Spouse A&B; Deps None |
$1,184.77 |
| 66 |
3 Party: Member None; Spouse A&B&D; Deps A&B&D |
$1,087.20 |
| 66a |
3 Party: Member None; Spouse A&B&D; Deps A&B |
$1,135.97 |
| 66b |
3 Party: Member None; Spouse A&B; Deps A&B&D |
$1,135.97 |
| 66c |
3 Party: Member None; Spouse A&B; Deps A&B |
$1,184.77 |
| FEE-FOR-SERVICE PLAN MEDICARE MONTHLY RATES (NON-CALIFORNIA RESIDENTS) - A Only, A&D |
| 67 |
Member A&D |
$565.07 |
| 67a |
Member A Only |
$614.83 |
| 68 |
Two Party: Both A&D |
$979.61 |
| 68a |
Two Party: Member A&D; Spouse A Only |
$1,029.36 |
| 68b |
Two Party: Member A Only; Spouse A&D |
$1,029.36 |
| 68c |
Two Party: Both A Only |
$1,079.13 |
| 68d |
Two Party: Member. None; Spouse A Only |
$1,279.69 |
| 68e |
Two Party: Member. None; Spouse A&D |
$1,229.91 |
| 68f |
Two Party: Member. A Only; Spouse None |
$1,279.69 |
| 68g |
Two Party: Member A&D; Spouse None |
$1,229.91 |
| 68h |
Two Party: Member A&D; Spouse B&D |
$1,002.66 |
| 69 |
3 Party: Member A&D; Spouse A&D; Deps A&D |
$850.60 |
| 69a |
3 Party: Member A&D; Spouse None; Deps None |
$1,351.23 |
| 69b |
3 Party: Member A Only; Spouse A Only; Deps None |
$1,200.46 |
| 69c |
3 Party: Member A&D; Spouse A Only; Deps None |
$1,150.70 |
| 69d |
3 Party: Member A Only; Spouse A&D; Deps None |
$1,150.70 |
| 69e |
3 Party: Member A&D; Spouse A&D; Deps None |
$1,100.93 |
| 69f |
3 Party: Member A Only; Spouse None; Deps A Only |
$1,200.46 |
| 69g |
3 Party: Member A&D; Spouse None; Deps A Only |
$1,150.70 |
| 69h |
3 Party: Member A Only; Spouse None; Deps A&D |
$1,150.70 |
| 69i |
3 Party: Member A&D; Spouse None; Deps A&D |
$1,100.93 |
| 69j |
3 Party: Member None; Spouse A Only; Deps None |
$1,401.00 |
| 69k |
3 Party: Member None; Spouse A&D; Deps None |
$1,351.23 |
| 69l |
3 Party: Member None; Spouse A Only; Deps A Only |
$1,200.46 |
| 69m |
3 Party: Member None; Spouse A&D; Deps A Only |
$1,150.70 |
| 69n |
3 Party: Member None; Spouse A Only; Deps A&D |
$1,150.70 |
| 69o |
3 Party: Member None; Spouse A&D; Deps A&D |
$1,100.93 |
| 69p |
3 Party: Member None; Spouse None; Deps A Only |
$1,401.00 |
| 69q |
3 Party: Member None; Spouse None; Deps A&D |
$1,351.23 |
| 69r |
3 Party: Member A Only; Spouse None; Deps None |
$1,401.00 |
| 70 |
3 Party: Member A&B&D; Spouse A&B&D; Deps A&B&D |
$901.27 |
| BLUE CARD PLAN RATES (Non-Medicare Residents Living Outside California Rates) |
| 40 |
Single |
$829.78 |
| 41 |
Two Party |
$1,277.02 |
| 42 |
Family |
$1,317.60 |
| PPO PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/09 |
| |
Prudent Buyer Incentive Plan |
Blue Card (Not Enrolled in Medicare) |
Fee-For-Service (Enrolled in Medicare) |
| CALENDAR YEAR DEDUCTIBLE |
$400 per individual. $800 family max. |
$400 per individual. $800 family max. |
$400 per individual. $800 family max. |
| OUT OF POCKET MAXIMUM |
$1,500 per individual (Excludes deductible, co-payments (ER and routine), mental or nervous disorder and chemical and substance abuse.) |
$1,500 per individual (Excludes deductible, co-payments (ER and routine), mental or nervous disorder and chemical and substance abuse.) |
$1,500 per individual (Excludes deductible, co-payments (ER and routine), mental or nervous disorder and chemical and substance abuse.) |
| LIFETIME MAXIMUM |
$5,000,000 per covered person |
$5,000,000 per covered person |
$5,000,000 per covered person |
| HOSPITAL SERVICES |
| EMERGENCY ROOM**(Co-pay is in addition to deductible) |
$75 co-pay**; waived if admitted |
$75 co-pay**; waived if admitted |
$75 co-pay**; waived if admitted |
| URGENT CARE VISITS |
For visits at an urgent care facility 90% Par1 70% Non-Par2 |
For visits at an urgent care facility 80% Par1 80% Non-Par2 |
For visits at an urgent care facility 80% |
| INPATIENT (Room, Board and Support Services) |
90% Par1 70% Non-Par2 (Failure to obtain pre-authorization of services will result in a 20% penalty if Medicare does not apply) |
80% Par1 80% Non-Par2 (Failure to obtain pre-authorization of services will result in a 20% penalty if Medicare does not apply) |
80% (Failure to obtain pre-authorization of services will result in a 20% penalty if Medicare does not apply) |
| INPATIENT MATERNITY CARE |
90% Par1 70% Non-Par2 |
80% Par1 80% Non-Par2 |
80% |
| PHYSICIAN SERVICES |
| OFFICE VISITS |
90% Par1 70% Non-Par2 |
80% Par1 80% Non-Par2 |
80% |
| PHYSICAL THERAPY, PHYSICAL MEDICINE, OCCUPATIONAL THERAPY CHIROPRACTIC SERVICES(limited to 24 visits/cal yr) |
90% Par, 70% Non-Par(Non-Par Services are limited to a maximum benefit of $25 per visit) |
80% Par, 80% Non-Par (Non-Par Services are limited to a maximum benefit of $25 per visit) |
80% |
| SPEECH THERAPY (outpatient speech therapy following injury or organic disease) |
90% Par, 90% Non-Par7 |
80% Par, 80% Non-Par7 |
80% |
| HEALTH MAINTENANCE |
| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBER AND DEPENDENTS |
Par and Non-Par 100% up to $250 per calendar year maximum. Not subject to the deductible. |
Par and Non-Par 100% up to $250 per calendar year maximum. Not subject to the deductible |
100% up to $250 per calendar year maximum. Not subject to the deductible |
| WELL WOMAN CARE |
90% Par1 70% Non-Par2 1 routine gynecology physical exam per calendar year. Includes breast and pelvic exams, mammogram & pap smears. |
80% Par1 80% Non-Par2 1 routine gynecology physical exam per calendar year. Includes breast and pelvic exams, mammogram & pap smears.2 |
80% 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% Par1 70% Non-Par2 |
80% Par1 80% Non-Par2 |
80% |
| CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE |
| INPATIENT HOSPITAL |
90% Par1 70% Non-Par2 30-days per calendar year, except for detoxification |
80% Par1 80% Non-Par2 30-days per calendar year, except for detoxification |
80% 30-days per calendar year, except for detoxification |
| OUTPATIENT HOSPITAL |
Par1: 50% up to $75/visit Non-Par2: 50% up to $25/visit. Up to 50 visits per calendar year participating and non-participating providers combined. |
50% up to $75/visit. Up to 50 visits per calendar year. |
50% up to $75 per visit; 50 visits per calendar year |
| MENTAL OR NERVOUS DISORDER |
| INPATIENT PROFESSIONAL 3 |
90% Par2 70% Non-Par3 |
80% Par2 80% Non-Par3 |
80% |
| OUTPATIENT PHYSICIAN SERVICES3 |
Par1: 50% up to $75/visit Non-Par2: 50% up to $25/visit. |
50% up to $75/visit |
50% up to $75 per visit. |
| OTHER COVERED EXPENSES |
| HEARING AID BENEFIT |
Plan pays 80% up to $1,500 for both ears every 3 years; deductible waived |
Plan pays 80% up to $1,500 for both ears every 3 years; deductible waived |
Plan pays 80% up to $1,500 for both ears every 3 years; deductible waived |
| PRESCRIPTION DRUGS - RETAIL PHARMACY (30-day supply) |
$15 for Generic, $25 for Brand4 20%(to a max. of $100 copay per prescription) for injectables5 |
$15 for Generic, $25 for Brand4 20%(to a max. of $100 copay per prescription) for injectables5 |
$15 for Generic, $25 for Brand4 20%(to a max. of $100 copay per prescription) for injectables5 |
| MAIL ORDER (90-day supply) |
$15 for Generic, $25 for Brand 20%(to a max. of $100 copay per prescription) for injectables5 |
$15 for Generic, $25 for Brand 20%(to a max. of $100 copay per prescription) for injectables5 |
$15 for Generic, $25 for Brand 20%(to a max. of $100 copay per prescription) for injectables5 |
| VISION CARE |
$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP). |
$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP). |
$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 is 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. Visit or day limits do not apply to certain mental health care described in the Evidence of Coverage. |
|
| 4. 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. |
|
| 5. The 20% co-pay does not apply to insulin. The standard co-pays of $15 Generic and $25 Brand Names apply to insulin. |
|
| 6. 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. |
|
| 7. 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. |
|
| 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. |
|
| 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. |
