Page 10 - Remita Guide 2020 - CA FINAL

Kaiser Kaiser Blue Shield Blue Shield
Permanente Permanente Trio ACO HMO Access+ HMO
Deductible HMO HMO
Network Name Kaiser Kaiser Trio Access+ HMO
Health Benefits
Deductible (Annual)
- Individual $1,500 $0 $0 $0
- Family $3,000 $0 $0 $0
Co-Insurance (Plan Pays) 70% 100% 100% 100%
Office Visit Copay
- Primary Care Physician $40 Copay $30 Copay $30 Copay $25 Copay
- Specialist Office Visit $40 Copay $30 Copay $30 Copay $25 Copay
$30 Self Refer $40 Self Refer
Out-of-Pocket Maximum
- Individual $4,000 $3,000 $1,500 $2,500
- Family $8,000 $6,000 $3,000 $5,000
Hospitalization
- Inpatient Deductible, 30% $500 Copay/Day No Charge $750/Admit
Max $1,500
- Outpatient Deductible, 30% $250 Copay No Charge $400 Copay
Lab and X-Ray $10 Copay $10 Copay No Charge No Charge
Emergency Services Deductible, 30% $150 Copay $100 Copay $150 Copay
Waived if Admitted
Urgent Care $40 Copay $30 Copay $30 Copay $25 Copay
Pharmacy Benefits
Pharmacy Deductible Does not apply to Tier 1 Does not apply to Tier 1
- Individual $0 $0 $150 / Member $150 / Member

Retail Pharmacy
- Tier 1 $10 Copay $15 Copay $15 Copay $15 Copay
- Tier 2 $30 Copay $35 Copay Ded, $30 Copay Ded, $30 Copay
- Tier 3 N/A N/A Ded, $45 Copay Ded, $45 Copay
- Tier 4 $30 Copay 30% up to $150 Ded, 20% up to $200 Ded, 20% up to $200
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $20 Copay $30 Copay $30 Copay $30 Copay
- Tier 2 $60 Copay $70 Copay Ded, $60 Copay Ded, $60 Copay
- Tier 3 N/A N/A Ded, $90 Copay Ded, $90 Copay
- Tier 4 N/A N/A Ded,20% up to $400 Ded,20% up to $400
- Supply Limit 100 Days 100 Days 90 Days 90 Days

Educational Video
Health Insurance Terms
http://video.burnhambenefits.com/terms