medical PLans

All Points Benefits (APB) Medical


LAPRA offers you and your family three medical options:


All three 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.


Anthem Blue Cross Prudent Buyer PPO Plan


The Anthem Blue Cross Prudent Buyer Plan is a Preferred Provider Organization (PPO) that gives you the option to see any provider (participating providers or non-participating providers) whenever you need care. If saving health care dollars is important to you, you will want to stay in-network by using only PPO doctors and hospitals. The Prudent Buyer PPO network is the largest provider network in California.


PPO Network Providers


PPO network providers are doctors, hospitals, pharmacies, labs, etc. that participate in the Anthem Blue Cross Prudent Buyer PPO network and have agreed to provide services at pre-negotiated reduced rates. When you use PPO network providers, you receive the highest level of benefits at the lowest possible cost. You are not required to choose a primary care physician and you can see doctors and specialists within the network without a referral. PPO providers file all claims for you.

After a PPO network calendar year deductible of $300 per person, or $600 per family, the Plan pays 90% of most covered PPO network services and you pay 10%. After a separate non-PPO network calendar year deductible of $500 per person, or $1,000 per family, the Plan pays 70% of most covered services and you pay 30%. The out-of-pocket calendar year maximum for PPO network services is $2,000 per person or $6,000 per family (not to exceed $2,000 for any one individual). A separate out-of-pocket calendar year maximum of $3,000 per person or $9,000 per family (not to exceed $3,000 for any one individual) applies for non-network services. The out-of-pocket maximum includes deductibles and medical and prescription drug co-pays, and excludes co-pays for infertility benefits.  

IMPORTANT: When using a non-network provider under the Anthem Blue Cross Prudent Buyer PPO Plan, the maximum allowable charge is based on the customary and reasonable charge for professional services as determined by Anthem Blue Cross. Members are responsible for any difference between the non-network provider’s actual charge and the maximum allowable charge, as well as any deductible and/or coinsurance percentage.

 

Effective July 1, 2017



Benefit Feature
Anthem Blue Cross Prudent Buyer PPO
Providers
PPO Network
Non-PPO Network1
Calendar Year Deductible
$300 per person, $600 per family
$500 per person, $1,000 per family
Calendar Year Out-of-Pocket Max (includes deductibles and medical co-pays; excludes co-pays for infertility benefits)
$2,000 per person
$6,000 per family (not to exceed $2,000 for any one individual)
$3,000 per person
$9,000 per family (not to exceed $3,000 for any one individual)
Lifetime Max
Unlimited
Unlimited
Office Visit
90%3
70%3
Hospitalization
90%3
70%3,4,5
Emergency Room
90% after $150 co-pay per visit (waived if admitted)
Urgent Care
90%3
70%3
Maternity Care
90%3
70%3
Well Baby/ Child Care
(up to age 7; not subject to deductible)
100%
70%3
Routine Physical
(adults; and children over age 7; not subject to deductible)
100%
Not covered
Diagnostic X-ray & Lab Tests 90%2 70%2
Body Scans
(not subject to deductible)
100% after $25 co-pay; up to $250 per calendar yr
Not covered
Physical & Occupational Therapy and Chiropractic Services (additional services may be authorized)
90%3 (24 visits per calendar yr combined PPO Network &
Non-PPO Network)
70%3 (24 visits per calendar yr combined PPO Network &
Non-PPO Network)
Acupuncture
(24 visits per calendar year)
90%3
70%3
Mental Health/Chemical Dependency
• Outpatient
• Inpatient



90%3
90%3



70%3
70%3,4,5

1 Benefits are based on the customary and reasonable charge. You are responsible for any difference between the amount charged and the customary and reasonable charge, plus any deductible and/or coinsurance amount.
2 If you are a retiree and you or a covered dependent is enrolled in Medicare Parts A and/or B, the PPO plan calendar year deductible is waived for you and all of your covered dependents.
3 Subject to calendar year deductible.
4 Failure to obtain pre-authorization may result in a $250 penalty.

5 Covered expense is reduced by 25% if a service or supply is provided by a non-contracted hospital.

 


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When You Need a Prescription


When you enroll in a LAPRA medical plan, you automatically receive prescription drug coverage as shown in the table below.

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 Blue Cross Prudent Buyer PPO
Calendar Year Prescription Drug Out-of-Pocket Maximum

$4,850 per person
$7,700 per family
(not to exceed $4,850 for any one person)

Retail Pharmacy
• Generic
1
• Brand

• Maintenance Drugs
• Injectables
2
• Retail Supply

 

$15 co-pay
$25 co-pay
2 co-pays (90-day supply)
 20% co-pay,
1 max $150/prescription

Up to 30 days (90 days for maintenance drugs3)

Mail Order
• Generic
1
• Brand
• Injectables
2
• Mail Order Supply

1-30 day supply / 31-90 day supply
$15 co-pay / $30 co-pay
$25 co-pay / $50 co-pay
20% co-pay,
1 max $150/script / 20% co-pay, max $300/script
Up to 90 days


1 $0 co-pay for women's prescription contraceptives.

2 20% co-pay does not apply to insulin. Regular co-pays apply.

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.



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.

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Premium Rates


Click on a link below for the 2016-2017 or 2017-2018 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.

 

  


 


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