Kaiser Permanente Traditional HMO Plan
With the Kaiser Permanente Traditional Health Maintenance Organization (HMO) plan, services must be obtained at a Kaiser Permanente facility, except in the case of emergency. Kaiser Permanente integrates all elements of healthcare such as physicians, medical centers, pharmacy and administration in one convenient facility. In addition, Kaiser Permanente offers online tools so you can email your doctor’s office, make appointments, refill prescriptions, and more. Kaiser Permanente HMO medical plan highlights include:
- There is no plan deductible.
- Services are only covered when you use Kaiser Permanente providers and facilities, except in the case of emergency.
- You must select a PCP from the pre-approved list of Kaiser Permanente healthcare providers. Each family member may choose his or her own PCP.
- Kaiser Permanente requires a referral from your PCP to see a specialist.
- Kaiser Permanente will file all claims on your behalf.
Download the Kaiser Permanente app on the Apple App Store or Google Play to access your health plan information 24/7 from your mobile device. You can use the app to view your benefits, make or change appointments, communicate with your doctor, refill prescriptions, view test results, access your medical records and contact Customer Service.
Anthem Blue Cross California Care HMO Plan
With the Anthem Blue Cross California Care Health Maintenance Organization (HMO) plan, you must choose a primary care physician (PCP) or medical group within the Anthem Blue Cross HMO network. All of your care must be directed through your PCP or medical group. Any specialty care you need will be coordinated through your PCP and will generally require a referral or authorization. You will receive benefits only if you use the doctors, clinics and hospitals that belong to the medical group in which you are enrolled, except in the case of an emergency. HMO medical plan highlights include:
- There is no plan deductible.
- Services are only covered when you use HMO network providers, except in the case of emergency.
- You must select a PCP or medical group from the HMO plan’s pre-approved list of healthcare providers. Each family member may choose his or her own PCP or medical group.
- The HMO plan requires a referral from your PCP to see a specialist.
- Your PCP will file all claims on your behalf.
Download the Anthem Blue Cross app on the App Store or Google Play to access your California Care HMO Plan information 24/7 from your mobile device. The Anthem Blue Cross app allows you to view your benefits, find a doctor or urgent care and get directions, access your medical ID card, refill prescriptions and contact Customer Service.
Anthem Blue Cross Prudent Buyer PPO Plan
With the Anthem Blue Cross Prudent Buyer Preferred Provider Organization plan, you are not limited to the physicians within the PPO network and you may self-refer to specialists. If you receive care from a physician who is a member of the PPO network, a greater percentage of the entire cost will be paid by the insurance plan. You may also obtain services using a non‐network provider; however, you will be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims. While this plan offers more flexibility than the HMO option, it is also the most costly option (see page 18 for a list of employee contributions). PPO medical plan highlights include:
- This plan includes a deductible for individual and family coverage.
- You may receive services from providers inside and outside the PPO network.
- You are not required to select a PCP or medical group.
- You are not required to obtain a referral to see a specialist.
- Most PPO network providers will file claims on your behalf. However, if you use the non-network tier of the plan, you may have to pay the provider in full and then file a claim for reimbursement.
- Out-of-pocket costs will be higher if you use non-network providers.
Download the Anthem Blue Cross app on the App Store or Google Play to access your Prudent Buyer PPO Plan information 24/7 from your mobile device. The Anthem Blue Cross app allows you to view your benefits, find a doctor or urgent care and get directions, access your medical ID card, refill prescriptions and contact Customer Service.
Anthem Blue Cross Preferred Generic Rx Program
If an Anthem Blue Cross member requests a formulary or non-formulary brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed charge for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost for that type of prescription drug.
The Preferred Generic Program does not apply when the physician has specified “dispense as written” (DAW) or when it has been determined that the brand name drug (formulary or non-formulary) is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply.
Summary of Benefits and Coverage (SBC)
Health insurance issuers and group health plans are required to provide you with an easy-to-understand summary about your health plan’s benefits and coverage. This regulation is designed to help you better understand and evaluate your health insurance choices.