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Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the
plans Evidence of Coverage.
Benefit (In-Network)
Kaiser Plan S Kaiser Plan L
Plan Year Deductible None None
Plan Year Out-of-Pocket Maximum
Individual $1,500 $1,500
Family $3,000 $3,000
Professional Services
Office Visits
Primary Care Provider $25 $5
Specialist $25 $5
Preventive Care No charge No charge
Diagnostic X-ray and Lab No charge No charge
Imaging (MRI, CT/PET scans) No charge No charge
Outpatient Therapy (Speech, Physical, etc.) $25 $5
Acupuncture $25 $5
Chiropractic Services (30 visits per 12-month period) $15 $10
Hospital and Facility Services
Inpatient Hospital and Physician Services No charge No charge
Outpatient Surgery $25 $5
Skilled Nursing Facility (100 days per benefit period) No charge No charge
Mental Health and Substance Abuse
Inpatient Facility No charge No charge
Outpatient Visit
Individual $25 $5
Mental Health: $12 Mental Health: $2
Group
Substance Abuse: $5 Substance Abuse: $2
Emergency Care
Emergency Room $50 (waived if admitted) $50 (waived if admitted)
Ambulance $50 $50
Home Health Care
No charge No charge
(100 visits per Accumulation Period)
Hospice Care No charge No charge
Durable Medical Equipment (DME) 20% 20%
Prescription Drugs
Retail 30-day supply 30-day supply
Generic $10 $5
Brand (Formulary) $25 $5
Brand (Non-Formulary) Same as brand when approved Same as brand when approved
Specialty Drugs $25 $5
Mail Order 100-day supply 100-day supply
Generic $20 $5
Brand (Formulary) $50 $5
Note: This is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Evidence of Coverage.
Current Proposed
Benefit (In-Network)
Anthem PPO UHC
In Network Out of Network In Network Out of Network
Medicare Coordination Medicare Supplement Medicare Replacement
Plan Year Deductible*
Individual $500 N/A
Family $1,000 N/A
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000 $1500 per Medicare member
Family $6,000 $45,000 (Medical only)
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40% $5 Copay $5 Copay
Specialist $20 (deductible waived) 40% $5 Copay $5 Copay
No charge (deductible
Preventive Care 40% No charge No charge
waived)
Diagnostic X-ray and Lab 20% 40% $5 Copay $5 Copay
Imaging (MRI, CT/PET scans) No charge No charge $5 Copay $5 Copay
Outpatient Therapy (Speech, Physical,
20% 40% $5 Copay $5 Copay
etc.)
Acupuncture 20% 40% $5 Copay $5 Copay
(12 visits per year w/ medical necessity) (30 visits per year)
Chiropractic Services 20% 40% $5 Copay $5 Copay
(12 visits per year w/ medical necessity) (30 visits per year)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% $40 No charge No charge
Outpatient Surgery $20 $40 $5 Copay $5 Copay
Skilled Nursing Facility 20% 40% No charge No charge
(100 days per benefit period) (100 days per benefit period)
Mental Health and Substance Abuse
Inpatient Facility 20% 40% No charge No charge
Outpatient Visit $20 (deductible waived) 40% $5 Copay $5 Copay
Emergency Care
$75 Copay (waived if $75 Copay (waived if
Emergency Room $50 (waived if admitted) + 20%
admitted) admitted)
Ambulance 20% No charge No charge
Home Health Care 20% 40% No charge No charge
(100 visits per calendar year) (No limit visit)
Hospice Care 20% No charge No charge
Durable Medical Equipment (DME) 20% 40% 20% 20%
Covered in full up to $2000 annual allowance
Hearing Aids One hearing aid every 3 years (per ear)
(combined)
Prescription Drugs (deductible waived)
Retail 30-day supply 30-day supply***
Generic $5 $5** $5 N/A
Brand (Formulary) $15 %15** $20 N/A
Brand (Non-Formulary) $30 $30** $50 N/A
Specialty Drugs $30 $30** $50 N/A
Mail Order 90-day supply 90-day supply***
Generic $10 N/A $10 N/A
Brand (Formulary) $25 N/A $40 N/A
Brand (Non-Formulary) $45 N/A $100
Specialty Drugs N/A N/A $100 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amount and costs in excess of the
prescription drug maximum allowed amount up to $250 per prescription
***Only available in-network except in case of emergency
County of Marin - 2019
Non-Medicare Retirees
Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Eviden
Current
Benefit (In-Network)
Anthem PPO
In Network Out of Network
Plan Year Deductible*
Individual $500
Family $1,000
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000
Family $6,000 $45,000
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40%
Specialist $20 (deductible waived) 40%
No charge (deductible
Preventive Care 40%
waived)
Diagnostic X-ray and Lab 20% 40%
Imaging (MRI, CT/PET scans) No charge No charge
Outpatient Therapy (Speech, Physical, etc.) 20% 40%
Acupuncture 20% 40%
(12 visits per year w/ medical necessity)
Chiropractic Services 20% 40%
(12 visits per year w/ medical necessity)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% $40
Outpatient Surgery $20 $40
Skilled Nursing Facility (100 days per benefit period) 20% 40%
Mental Health and Substance Abuse
Inpatient Facility 20% 40%
Outpatient Visit $20 (deductible waived) 40%
Emergency Care
Emergency Room $50 (waived if admitted) + 20%
Ambulance 20%
Home Health Care (100 days per calendar year) 20% 40%
Hospice Care 20%
Durable Medical Equipment (DME) 20% 40%
Hearing Aids One hearing aid every 3 years (per ear)
Prescription Drugs (deductible waived)
Retail 30-day supply
Generic $5 $5**
Brand (Formulary) $15 %15**
Brand (Non-Formulary) $30 $30**
Specialty Drugs $30 $30**
Mail Order 90-day supply
Generic $10 N/A
Brand (Formulary) $25 N/A
Brand (Non-Formulary) $45 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amou
prescription drug maximum allowed amount up to $250 per prescription
***Paid on the plans UCR (Usual, Customary and Reasonable) allowance. Patient responsible for anything over UCR
and limitations, please refer to the plans Evidence of Coverage.
Proposed
Teamsters Anthem PPO
In Network Out of Network
$250
$500
Unlimited
20% 40%***
20% 40%***
20% 40%***
20% 40%***
(15 visits per year w/ medical necessity)
20% S
(40 visits per year w/ medical necessity)
20% 40%***
20% 50%***
20% 40%***
20% 50%***
20% 50%***
20% 50%***
20% 50%***
20% 40%***
20% 40%***
20% 40%***
$1,000 every 3 years (per ear)
30-day supply
$10
$20
$20
N/A
90-day supply
$10
$20
$20
ining prescription drug maximum allowed amount and costs in excess of the
Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Eviden
Current
Benefit (In-Network)
Anthem PPO
No charge (deductible
Preventive Care 40%
waived)
N/A N/A
N/A N/A
$1,500 N/A
$3,000 N/A
$15
Not covered
(20 visits per year)
$15
Not covered
(20 visits per year)
30-day supply
$5 Not covered
$20 Not covered
$20 Not covered
$50 Not covered
90-day supply
$10 Not covered
$40 Not covered
$100 Not covered
maining prescription drug maximum allowed amount and costs in excess of the
County of Marin - Retirees 2019
Emergency Care
Emergency Room $50 (waived if admitted) + 20%
Ambulance 20%
Home Health Care
20% 40%
(100 visits per Accumulation Period)
Hospice Care 20%
Durable Medical Equipment (DME) 20% 40%
Hearing Aids One hearing aid every 3 years (per ear)
Prescription Drugs (deductible waived)
Retail 30-day supply
Generic $5 $5**
Brand (Formulary) $15 %15**
Brand (Non-Formulary) $30 $30**
Specialty Drugs $30 $30**
Mail Order 90-day supply
Generic $10 N/A
Brand (Formulary) $25 N/A
Brand (Non-Formulary) $45 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amou
prescription drug maximum allowed amount up to $250 per prescription
etirees 2019
Current Kaiser
None None
None None
$1,500 $1,500
$3,000 $3,000
$25 $5
$25 $5
No charge No charge
No charge No charge
No charge No charge
$25 $5
$25 $5
$15 $10
(30 visits per 12-month period)
No charge No charge
$25 $5
No charge No charge
No charge No charge
$25 $5
Mental Health: $12 Mental Health: $2
Substance Abuse: $5 Substance Abuse: $2
No charge No charge
No charge No charge
20% 20%