LAPRA offers you and your family four medical options:
All four plans provide coverage for preventive care, office visits, hospitalization, surgery and prescription drugs. The plans differ in co-payments, coinsurance, out-of-pocket costs, and provider choice. Plan highlights and monthly premiums may be found in your Enrollment Guide. Plan highlights and monthly premiums may be found in 2023-2024 Benefits Guide for Retired Members and the 2023-2024 Retiree Medical and Dental Premium Rates Booklet.
The Anthem HMO offers comprehensive coverage for a wide range of health care services. Benefits are payable only when you use Anthem HMO providers and facilities. Under the “Plus” benefits, you have the option to choose providers outside of the HMO network for certain outpatient services and still receive limited benefits for those services. Refer to your Enrollment Guide for details. There are no deductibles and no claim forms.
You pay a $20 co-pay for most services. The calendar year out-of-pocket co-pay maximum is $1,000 per person and $3,000 per family.
The out-of-pocket maximum includes prescription drug co-pays, and excludes
co-pays for infertility benefits. You must choose a Primary Care Physician (PCP) from a Participating Medical Group or Independent Practice Association in the Anthem HMO network. Your PCP manages all of your medical care, refers you to specialists as needed, and can help you take advantage of special wellness programs. This plan is only available to California residents.
Effective July 1, 2023
Benefit Feature |
Anthem HMO (California Residents Only) |
|---|---|
| Providers | HMO Providers Only1 |
| Calendar Year Deductible | N/A |
| Calendar Year Out-of-Pocket Max (excludes co-pays for infertility benefits) |
$1,000 per person, $3,000 per family |
| Lifetime Max | Unlimited |
| Office Visit | $20 co-pay |
| Hospitalization | 100% |
| Emergency Room | $150 co-pay (waived if admitted) |
| Urgent Care | $20 co-pay |
| Maternity Care | Doctor visits: $20 co-pay (initial visit only) Facility charges: 100% |
| Well Baby/ Child Care (up to age 7) |
100% |
| Routine Physical (adults and children over age 7) |
100% |
| Diagnostic X-ray & Lab Tests | 100% |
| Body Scans | Not Covered |
| Physical & Occupational Therapy and Chiropractic Services (additional services may be authorized) | $20 co-pay (limited to a 60-day period of care after illness or injury; additional visits available when approved by the medical group) |
| Acupuncture (24 visits per calendar year) |
$20 co-pay |
| Mental Health/Chemical Dependency • Outpatient • Inpatient |
$20 copay 100% |
1 Your primary care physician can refer you to a specialist when necessary and must approve all care you receive except in the event of an emergency.
When you enroll in a LAPRA medical plan, you automatically receive prescription drug coverage as shown in the table below.
Note that prescription drugs count towards your medical plan calendar
out-of-pocket maximum.
To save money, request that your doctor write your prescriptions for “generic” drugs whenever possible. Generic drugs are often the therapeutic equivalent of their brand-name counterparts, but cost significantly less.
You can purchase up to a 90-day supply of most maintenance drugs at a retail pharmacy. Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. Also, women's generic prescription contraceptives are covered with a $0 co-pay to comply with requirements of the Affordable Care Act.
| Prescription Drugs | Anthem PPO |
|---|---|
| Calendar Year Prescription Drug Out-of-Pocket Maximum |
$4,850 per
person $7,700 per family |
Retail Pharmacy • Non-formulary • Maintenance Drugs3 |
$15 co-pay1 $40 co-pay Up to 30 days (90 days for maintenance drugs3) |
Mail Order • Specialty Drugs4 • Mail Order Supply |
1-30 day supply / 31-90
day supply $40 co-pay
/ $80 co-pay |
1 $0 co-pay for women's prescription contraceptives.
2 Under the Anthem Blue Cross PPO plan, you will have to pay the co-pay for the generic drug plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug, but not more than 50% of the average cost for the tier that the brand name drug is in.
3 Maintenance drugs are those used to treat chronic conditions and are typically taken on a regular basis. To determine if your medication qualifies as a maintenance drug, contact Anthem Blue Cross at 800-700-2541. Maintenance drugs do not include any controlled substances, smoking cessation or weight management medications.
4 20% co-pay does not apply to insulin. Regular co-pays apply.
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, you cost will be less.
Click here for the 2023-2024 retiree medical and dental premium rates. Your cost is the monthly premium rate minus the Pension Department subsidy, based on your 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, you 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 B.
This brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Anthem Blue Cross contract. Please refer to your plan’s Evidence of Coverage for details on your benefits.