Medical
Medical coverage offers healthcare protection for you and your family. Under the HDHP plan, you may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits. Please note that HMO plans offer coverage for in-network providers only.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Blue Shield HDHP
Plan Information
Plan Name: Blue Shield HDHP
Policy Number: W8002394
Effective Date: 01/01/2025
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family Member/Family)
$1,650/$3,300/$3,300
Out-of-Pocket Max (Individual/Family Member/Family)
$3,000/$3,500/$6,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
$150 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay after deductible
Non-Preferred Brand
$40 copay after deductible
Specialty
30% after deductible ($250 max)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$80 copay after deductible
Specialty
30% after deductible ($500 max)
Out-of-Network
Deductible (Individual/Family Member/Family)
$1,650/$3,300/$3,300
Out-of-Pocket Max (Individual/Family Member/Family)
$5,000/$5,000/$10,000
Preventive Care
Not covered
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$150 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay + 25% after deductible
Preferred Brand
$25 copay + 25% after deductible
Non-Preferred Brand
$40 copay + 25% after deductible
Specialty
30% after deductible ($250 max) + additional 25% of purchase price
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Blue Shield HMO
Plan Information
Plan Name: Blue Shield HMO
Policy Number: W8002394
Effective Date: 01/01/2025
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay (referred by PCP)
$30 copay (Access+ specialist / self-referral)
Urgent Care
$15 copay
Emergency Room
$100 copay (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$45 copay
Specialty
20% (up to $250 per prescription)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$90 copay
Specialty
20% (up to $500 per prescription)
Plan Documents
Contact Information
Kaiser HMO
Plan Information
Plan Name: Kaiser HMO
Policy Number: 2064
Effective Date: 01/01/2025
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$50 copay (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay (when approved)
Specialty
$30 copay (when approved)
Mail-Order Rx (Up to 100-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Specialty
$30 (when approved, up to 30 day supply)