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4
How It Works
After the applicable calendar year deductible is met,
the plan pays 90% of most covered services.
When the deductible and other out-of-pocket
expenses for covered services total the applicable
calendar year out-of-pocket maximum, the plan
begins to pay covered charges at the 100% level for
the remainder of the year. There are separate out-
of-pocket maximums for medical charges and for
prescription drug expenses.
As shown in the comparison charts on pages 6 and 7,
deductible amounts and out-of-pocket maximums
differ for individual or family coverage, and are
higher for non-network providers than for network
providers.
IMPORTANT: If services are received from a non-
participating provider, you may be billed by the
provider for the difference between their charges
and your plan’s maximum allowed amount. The
maximum allowed amount is the total reimbursement
payable under your plan for covered services you
receive from providers.
Medical
LAPRA offers you and your family three medical options:
• Anthem Blue Cross Prudent Buyer PPO
• Anthem Blue Cross CaliforniaCare Plus HMO
• Kaiser HMO
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.
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.
Need Help?
Want to change doctors? Need an ID
card? Call Anthem Blue Cross, at the toll
free number listed on the back cover of
this Guide if you want to change doctors,
request a new ID card, or have your claim or
benefit questions answered. For questions
regarding eligibility or to request an ID card,
call a LAPRA Benefits Representative at
213-674-3701 or 888-252-7721 or send
an email to
benefits@lapra.org.If you
are new to the plan, you will receive an
identification card shortly after you enroll.
If you need care before your card arrives,
make an appointment and explain that you
are a new plan member.