A PPO is a group of medical care providers that agrees to provide medical services at a discount to a specified group (network providers). Like traditional fee-for-service indemnity health plans, employees are offered freedom of choice in how they receive medical treatment. However, PPOs are generally designed to encourage use of the network by either reimbursing a higher percentage of charges by PPO providers or applying higher deductibles and out-of-pocket maximums to services obtained outside the network.

Almost 95% of the physicians in the State are Blue Shield Preferred Providers - check with your employer to see if your company offers one of these plans:

PPO 90/70:  $6,000,000 maximum, $100 deductible per person, $200 per family, 10% co-payment, and $1,000 out-of-pocket limit per person on services from preferred physicians and preferred hospitals. $250 deductible per person, $500 per family, 30% co-payment, and $3,000 out-of-pocket limit per person for non-preferred services. Prescription drugs covered with a co-payment of $5.00 for generic, $10.00 for formulary brand name and $25.00 for non-formulary.

HMO: No deductible, $15 co-payment for office visits, annual copayment maximum of $1,000 per individual and $2,000 per family. Coverage for most other health care expenses if rendered by your selected Blue Shield Primary Care Provider is summarized
on the attached Comparison of Benefits Prescription drug coverage is shown on the attached benefit summary.

PPO/HRA: $6,000,000 lifetime maximum, $1,500 deductible per person, $3,000 per family, 20% co-payment and $4,500 out-of-pocket limit per person on services from preferred physicians and preferred hospitals- $3,000 deductible per person, $9,000 per family for in network services .For out of network services there is a 40% co-payment and $9,000 out-of-pocket limit per person for non-preferred services. The first $1,000 for Single and $2,000 for family of charges applied to the deductible will be paid by the HRA Plan which is funded by your employer. Prescription drugs coverage is shown on the attached benefit summary.

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As an alternative to the Health Care Program, you can enroll in a health maintenance organization (HMO) if one is available in your geographic area. An HMO is an organized system of medical care offering its members a comprehensive range of health services. These services are coordinated by a team of doctors associated with the HMO. If you enroll in an HMO, you are subject to the terms and conditions dictated by the HMO. An HMO does not guarantee that the doctors, hospitals and other providers currently participating in the plan will continue with the HMO or that the benefits will not change throughout the year. More information about HMOs is available from your Human Resources Department.

Kaiser- Southern California:

No deductible, $10 co-payment for office visits and prescription drugs, $35 for emergency room, 100% coverage for most other health care at Kaiser facilities, major medical centers and medical offices located in the major metropolitan areas of Southern California.

Kaiser - Northern California:

No deductible, $15 co-payment for office visits, $10 for generic prescription drugs and $20 for brand name drugs, $50 for emergency room, 100% coverage for most other health care at Kaiser facilities, major medical centers and medical offices located in the major metropolitan areas of Northern California.

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