Page 14 - City of Newport City BG- Full Time

2020 CalPERS Basic Medical Plans

The PORAC (only available to dues paying members in the Police and Fire bargaining units) plan by Anthem Blue
Cross gives access to a network of health care providers known as preferred providers without receiving a referral
or advance approval. This plan is only available to dues paying members in the Police, Fire and Lifeguard
Management bargaining units. See the CalPERS PORAC PPO Evidence of Coverage booklets for more detailed
information.

CalPERS PORAC PPO

In-Network Out-Of-Network
Annual Deductible $300 individual $600 individual
$900 family $1,800 family

Annual Out-of-Pocket Max $2,000 individual
N/A
$4,000 family
Office Visit - Primary Provider $35 copay (reduced to $10 if enrolled You pay 20% after deductible
with a personal doctor)

Office Visit - Specialist $35 copay You pay 20% after deductible
Preventive Services
No charge No charge

Chiropractic Care & Acupuncture $20 copay (20 visits per year
chiropractic care) You pay 20% after deductible

Lab and X-ray You pay 20% after deductible You pay 20% after deductible

Durable Medical Equipment You pay 20% (Pre-certification
required) You pay 20% (Pre-certification required)

Inpatient Hospitalization You pay 20% after deductible You pay 20% after deductible

Urgent Care $35 copay You pay 20% after deductible
Emergency Room You pay 20% You pay 20%

Prescription 30-day supply or 100/pills $10 copay
Generic $10 copay $25 copay
Brand $25 copay $45 copay
Non- formulary $45 copay Compound: $45
Compound: $45

Mail Order
Generic $20 copay N/A
Brand $40 copay
Non-formulary $75 copay

These are not summary plan descriptions (SPDs). If any discrepancy exists between this summary and the official documents, the official
documents will prevail.

12