Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive 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.
Kaiser HMO (includes Vision)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/Up to $3,000
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$5 copay
Urgent Care
$5 copay
Emergency Room
$50 copay
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Formulary
$5 copay
Non-Formulary
$5 copay (Non-preferred brand drugs must be approved through exception process)
Mail-Order Rx (Up to 100-Day Supply)
Generic
$5 copay
Formulary
$5 copay
Non-Formulary
$5 copay (Non-preferred brand drugs must be approved through exception process)
Weekly Plan Cost
Employee Only: $6.00
Employee + 1: $16.00
Employee + 2+: $21.00
Blue Shield/DHS EPO & VSP (includes vision)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$4,500
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$10 copay
Urgent Care
$10 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$10
Formulary
$25
Non-Formulary
$40
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Formulary
$50
Non-Formulary
$80
Weekly Plan Cost
Employee Only: $7.00
Employee + 1: $17.00
Employee + 2+: $22.00
Blue Shield/DHS PPO & VSP (includes vision)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
10% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$5
Formulary
$15
Non-Formulary
$35
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10
Formulary
$30
Non-Formulary
$70
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% of eligible cost after copays
Formulary
50% of eligible cost after copays
Non-Formulary
50% of eligible cost after copays
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Formulary
Not covered
Non-Formulary
Not covered
Weekly Plan Cost
Employee Only: $19.00
Employee + 1: $31.00
Employee + 2+: $37.00
Blue Shield/DHS HDHP & VSP (includes vision)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
10% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$5
Formulary
$15
Non-Formulary
$35
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10
Formulary
$30
Non-Formulary
$70
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% of eligible cost after copays
Formulary
50% of eligible cost after copays
Non-Formulary
50% of eligible cost after copays
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Formulary
Not covered
Non-Formulary
Not covered
Weekly Plan Cost
Employee Only: $7.00
Employee + 1: $17.00
Employee + 2+: $22.00