Medical Plan Options
Active participants may select from three medical plans: Kaiser HMO, the BlueShield of California HMO, and the BlueShield of California PPO. You can enroll in the BSCA PPO plan only if you do not reside in one of the HMO service areas.
Under the HMO options (Kaiser and BSCA), you must select a Primary Care Physician. This is the doctor you must always visit for all of your care. If you need to see a Specialist, your doctor will send you to another doctor for the necessary services. Kaiser participants must visit Kaiser facilities. Participants in the BSCA PPO plan may visit any provider. Your benefits will be higher when you visit providers who are contracted with the BSCA PPO.
This chart can help you to compare many plan features side-by-side:
|Kaiser||BlueShield HMO||BlueShield PPO|
|Network||Enrollees in Kaiser must receive all their care at Kaiser clinics and hospitals.||Enrollees in the BSCA HMO must receive all care at the Medical Group in which you enroll. Each family member may select a different Primary Care Physician (PCP) as long as they work at the same Medical Clinic. Care not authorized by your Medical Group is not covered.||Participants in the BSCA PPO may visit any provider. Your benefits will be greater, though, when you visit a provider who is contracted with the BSCA PPO.|
|Calendar Year Deductible||$2,000 per person/ $4,000 per family. Member has plan-issued debit card to cover expenses of $2,000 per person/$4,000 per family.||None||PPO: $750 per person/ $1,500 per family.
Non-PPO: $1,500 per person/$3,000 per family
|Office Visits: $30
Inpatient Hospital: $250 per admission
Emergency Room: $100 (waived if admitted after deductible met)
|Office Visits: $40 for primary care physician/ $55 for specialist.
Hospitalization: Plan pays 60% after $100 copay.
Emergency Room: $100 copay waived if admitted.
|Office Visits: PPO: $25 co-payment (deductible does not apply); non-PPO: Plan pays 60%.
Hospitalization: PPO: Plan pays 60% after $100 copay; non-PPO: plan pays 60%.
Emergency Room: $100 copay per visit, then 80%.
|Out of Pocket Maximum per calendar year||$3,000 per person/$6,000 per family||$3,500 per person/$7,000 per family||PPO: $4,750 per person/ $9,500 per family
Non-PPO: $9,500 per person/ $19,000 per family
|Prescription Drug||$10 generic/ $30 brand||$15 generic/ $30 formulary brand – $150 deductible on brand name drugs||$10 generic/ $30 formulary brand
$50 NON formulary brands