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2022 medical option
coverage summaries
For retirees and/or family members who aren’tyet Medicare-eligible
Table of contents
If you and/or your family members are not yet eligible for Medicare (due to age or disability), you can each
enroll in:
• An HP medical option available in your ZIP code (as shown on your personalized statement), or
• An individual insurance option through a public health exchange (marketplace).
This document provides summaries of all HP non-Medicare medical options. Click on the name of a
medical option below to go directly to that medical option’s summary.
Aetna CDHP w/HRA........................................................................................................................................................................ 1
Aetna EPO........................................................................................................................................................................................ 3
Aetna HDHP (pre-65 option) ........................................................................................................................................................ 5
Aetna Premium PPO...................................................................................................................................................................... 7
Aetna Value PPO ............................................................................................................................................................................ 9
Anthem BCBS Basic CMP.............................................................................................................................................................11
Anthem BCBS CDHP w/HRA........................................................................................................................................................13
Anthem BCBS EPO .......................................................................................................................................................................15
Anthem BCBS HDHP (pre-65 option) ........................................................................................................................................17
Anthem BCBS Premium CMP......................................................................................................................................................19
Anthem BCBS Premium PPO......................................................................................................................................................21
Anthem BCBS Standard CMP......................................................................................................................................................23
Anthem BCBS Value PPO ............................................................................................................................................................25
Blue Essentials HMO....................................................................................................................................................................27
Cigna CDHP w/HRA ......................................................................................................................................................................29
Cigna EPO ......................................................................................................................................................................................31
Cigna HDHP (pre-65 option).......................................................................................................................................................33
Cigna Premium PPO.....................................................................................................................................................................35
Cigna Value PPO ...........................................................................................................................................................................37
HMSA PPO .....................................................................................................................................................................................39
Kaiser (Hawaii) ..............................................................................................................................................................................41
Kaiser HMO (Colorado) ................................................................................................................................................................43
Kaiser HMO (Georgia)...................................................................................................................................................................45
Kaiser HMO (Hawaii) (pre-65 option) ........................................................................................................................................47
Kaiser HMO (Mid-Atlantic) ...........................................................................................................................................................49
Kaiser HMO (NorthWest) .............................................................................................................................................................51
Kaiser HMO (Northern CA)...........................................................................................................................................................53
Kaiser HMO (Southern CA) ..........................................................................................................................................................55
1
Aetna CDHP w/HRA
Plan Facts
Member services phone number 1-800-545-5810
Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone
Web site address www.aetna.com; network name: Choice POS II
This coverage summary provides an overview of benefits available under the Aetna CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,300 Individual; $3,900 Family $1,950 Individual; $5,850 Family; separate from in-network
Annual HP-Funded Health
Reimbursement Account
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$6,950 Individual; $20,850 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 80% covered after deductible is met 50% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive
services
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered for emergency; non-emergency 80%
covered after deductible is met
$200 copay then 90% covered for emergency; non-emergency
50% covered after deductible is met
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to 10 visits per
calendar year; combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 50% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
2
Aetna CDHP w/HRA
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 60% cov; $45 min/$90 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day
supply available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible
for non-preventive services; check with Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for
non-preventive services; check w/Plan for preventive sched
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Infertility services 90% inpatient; 80% outpatient; after deductible is met; limited to
$10,000 per family per lifetime, $5,000 for Rx and $5,000 for medical
svcs; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered 50% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered 50% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 50% cov after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
3
Aetna EPO
Plan Facts
Member services phone number 1-800-545-5810
Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone
Web site address www.aetna.com; network name: Open Access Aetna Select
This coverage summary provides an overview of benefits available under the Aetna EPO medical plan for the year 2022. Keep in mind that this is only a summary, and does
not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment, coverage may
vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at
90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at
the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,300 Family; includes deductible and copays; includes MH/SU; Rx copays excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay; then 90% covered
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Outpatient occupational therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Outpatient speech therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar year
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of service and service performed
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar year
Effective January – December 2022
4
Aetna EPO
Coverage Highlights In-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Nonparticipating pharmacies not covered (Retail and Mail Order)
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 3 60% cov; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; limited to one exam per calendar year; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with
Plan for preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with
Plan for preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable cost share
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified Covered; copay based on location of services
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded; inpatient; ltd to $10,000 per family per lifetime; $5,000 for
Rx and $5,000 for all medical services; check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for T1 contraceptives; applicable Rx copay/coinsurance applies for
other tiers
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 100% covered; limited to 120 visits per calendar year
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 100% covered; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
5
Aetna HDHP (pre-65 option)
Plan Facts
Member services phone number 1-800-545-5810
Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone
Web site address www.aetna.com; network name: Choice POS II
This coverage summary provides an overview of benefits available under the Aetna HDHP medical plan for the year 2022. Keep in mind that this is only a summary, and
does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$2,000 Individual; $4,000 Family $4,000 Individual; $8,000 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$6,750 Individual; $13,500 Family; with embedded $8,150 individual
OOP limit for family coverage; includes deductible; includes Rx and
MH/SU
$13,500 Individual; $27,000 Family; with embedded $13,500
individual OOP limit for family coverage; includes deductible;
includes Rx and MH/SU; separate from in-network
Primary Doctor Office Visit 80% covered after deductible is met 60% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive
services
60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered after Plan deductible is met 80% covered after Plan deductible is met
• Urgent care clinic visit (facility) 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 60% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 30 visits per year;
combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 10 visits per year;
combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 60% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to $500 per year;
combined in and out-of-network
Effective January – December 2022
6
Aetna HDHP
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Some preventive Rx not subject to deductible
Retail
• Tier 1 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 2 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 3 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
Mail Order 80% covered after deductible is met; provides cost savings and
convenience for a 90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through CVS Specialty Pharmacy Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible
for non-preventive services; check with Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for
non-preventive services; check w/Plan for preventive sched
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
60% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 60% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for medical svcs; check with Plan
for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1
contraceptives; applicable coinsurance and deductible applies for
other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable coinsurance and deductible
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Rehab: inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 60% cov after ded is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 visits per calendar year;
combined in and out-of-network
• Hospice care 80% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 days per calendar year;
combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
7
Aetna Premium PPO
Plan Facts
Member services phone number 1-800-545-5810
Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone
Web site address www.aetna.com; network name: Choice POS II
This coverage summary provides an overview of benefits available under the Aetna Premium PPO medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where services
are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible expenses after
the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$650 Individual; $1,950 Family $1,300 Individual; $3,900 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$6,150 Individual; $18,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and
coinsurance
$4,200 Individual; $8,400 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit $20 copay 60% covered after deductible is met
Specialist Office Visit $45 copay; 100% covered for preventive services 60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered for emergency; non-emergency 90%
covered after deductible is met
$200 copay then 90% covered for emergency; non-emergency
60% covered after deductible is met
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist 60% covered after deductible is met
• Outpatient laboratory services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
$20 copay PCP; $45 copay specialist; limited to 30 visits per calendar
year; combined in-network and out-of-network; costs may vary
based on place of service
60% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to 10 visits per
calendar year; combined in and out-of-network
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of
service and service performed
60% covered after deductible is met
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
8
Aetna Premium PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 $40 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 $55 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) $100 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable cost share
60% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met 60% covered after deductible is met
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded inpatient;
limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000
for all medical services; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for T1 contraceptives;
applicable Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $20 copay 60% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay 60% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 90% cov after deductible is met; limited to one pair per lifetime 60% cov after ded is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 90% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 90% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
9
Aetna Value PPO
Plan Facts
Member services phone number 1-800-545-5810
Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone
Web site address www.aetna.com; network name: Choice POS II
This coverage summary provides an overview of benefits available under the Aetna Value PPO medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,700 Individual; $5,100 Family $2,500 Individual; $7,500 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$7,250 Individual; $21,750 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 100% cov; up to $250; then 80% cov after ded is met; $250 ann limit
is cmbnd for all office visits
50% covered after deductible is met
Specialist Office Visit 100% covered up to $250; then 80% covered after deductible is
met; 100% covered for preventive services; $250 annual limit is
combined for all office visits
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered for emergency; non-emergency 80%
covered after deductible is met
$200 copay then 90% covered for emergency; non-emergency
50% covered after deductible is met
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 100% covered up to $250; then 80% covered after deductible is
met; $250 annual limit is combined for all office visits
50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services 100% covered; up to $250; then 80% covered after ded; limited to
10 visits per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
100% covered; up to $250; then 80% covered after ded; limited to
10 visits per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
• Allergy tests and treatments 100% covered up to $250 for office visit charges only; other services
80% covered after deductible is met; $250 annual limit is combined
for all office visit services
50% covered after deductible is met
• Acupuncture 100% covered; up to $250; then 80% covered after ded; limited to
$500 per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
100% covered; up to $250; then 80% covered after ded; limited to
$500 per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
Effective January – December 2022
10
Aetna Value PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 65% covered; $35 min/$75 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 55% covered; $50 min/$105 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $80 min/$140 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 50% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 50% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 50% covered after deductible is met
• Infertility services 80% covered after ded is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for all medical services; check with
Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Rehab: inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime 50% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 80% covered after deductible is met 50% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
11
Anthem BCBS Basic CMP
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca
This coverage summary provides an overview of benefits available under the Anthem BCBS Basic CMP medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. You may qualify to receive services at discounted rates
when you use Anthem BCBS network providers. For additional information and details about benefits under this medical plan, call the member services department at the
number(s) shown above.
Coverage Highlights Benefits
Annual Deductible
Individual/Family
$5,150 Individual; $15,450 Family
Out-of-Pocket Maximum
Individual/Family
$7,150 Individual; $21,450 Family; includes deductible; copays not included; includes MH/SU
Primary Doctor Office Visit 80% covered after deductible is met; 100% covered for preventive services
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay $100 copay per admission
Hospital Coinsurance 80% covered after hospital copay and Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) 80% covered after deductible is met
• Urgent care clinic visit (facility) 80% covered after deductible is met
Inpatient Care
• Inpatient surgery 80% covered after hospital copay and Plan deductible is met
• Physician/Surgeon services 80% covered after hospital copay and Plan deductible is met
• Inpatient lab and X-ray services 80% covered after hospital copay and Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met
• Outpatient physical therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient occupational therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient speech therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar year
• Allergy tests and treatments 80% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar year
Effective January – December 2022
12
Anthem BCBS Basic CMP
Coverage Highlights Benefits
Prescription Drug Coverage* Administered by Anthem
Non participating pharmacies: member must submit claim to administrator for reimbursement after paying full out
of pocket cost
Retail
• Tier 1 80% covered after deductible is met
• Tier 2 80% covered after deductible is met
• Tier 3 80% covered after deductible is met
• Tier 4 (ED/sleep aids) 80% covered after deductible is met
Mail Order Not covered
Specialty Drug Program Check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable coinsurance/deductible
• In-hospital doctor's services 80% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000 for
medical services; check with Plan for details
• Oral contraceptives Retail available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for other tiers
Mental Health Care
• Outpatient coverage/visits 80% covered
• Inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Substance Use Disorder
• Rehab: outpatient coverage/visits 80% covered
• Rehab: inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar year
• Hospice care 80% covered after deductible is met
• Prescribed care in a noncustodial skilled nursing facility 80% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 80% covered after deductible is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible expenses are limited to the reasonable and customary (R&C) amount charged for a particular service in a
particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be covered at
all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and exclusions,
contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Cost for brand-name drugs—If your doctor writes “dispense as written” for a brand-name drug that has a generic equivalent, you will pay the difference between the higher cost brand-name drug and the
lower cost generic drug, plus your cost-share for the drug. For information on in-network retail locations, or for any prescription drug information, go to www.anthem.com/ca, or call 1-800-364-3301.
13
Anthem BCBS CDHP w/HRA
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)
This coverage summary provides an overview of benefits available under the Anthem BCBS CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network
providers (“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member
services department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,300 Individual; $3,900 Family $1,950 Individual; $5,850 Family; separate from in-network
Annual HP-Funded Health
Reimbursement Account
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays; Rx
copays excluded; includes MH/SU
$6,950 Individual; $20,850 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 80% covered after deductible is met 50% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered; preventive
services
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered for emergency; non-emergency 80% covered after
deductible is met
80% covered for emergency; non-emergency 50% covered after
deductible is met
• Urgent care clinic visit (facility) 80% covered 80% covered
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to 10 visits per
calendar year; combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 50% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
14
Anthem BCBS CDHP w/HRA
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day
supply available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through CVS Specialty Pharmacy Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% cov for preventive services; 80% cov after deductible for
non-preventive services; check w/Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after deductible for
non-preventive services; check w/Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Infertility services 90% inpatient; 80% outpatient; after deductible is met; limited to
$10,000 per family per lifetime, $5,000 for Rx and $5,000 for medical
svcs; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered 50% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered 50% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 50% cov after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
15
Anthem BCBS EPO
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)
This coverage summary provides an overview of benefits available under the Anthem BCBS EPO medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment,
coverage may vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services
and paid at 90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,300 Family; includes deductible and copays; includes MH/SU; Rx copays excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay; then 90% covered
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Outpatient occupational therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Outpatient speech therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar year
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of service and service performed
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar year
Effective January – December 2022
16
Anthem BCBS EPO
Coverage Highlights In-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Nonparticipating pharmacies not covered (Retail and Mail Order)
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; limited to one exam per calendar year; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; copay
based on place of service and services performed; check with Plan for preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; copay
based on place of service and services performed; check with Plan for preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable cost share
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified Covered if contracted; copay based on location of services
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded is met inpatient; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for all medical services; check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for
other tiers
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 100% covered; limited to 120 visits per calendar year
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 100% covered; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
17
Anthem BCBS HDHP (pre-65 option)
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)
This coverage summary provides an overview of benefits available under the Anthem BCBS HDHP medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$2,000 Individual; $4,000 Family $4,000 Individual; $8,000 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$6,750 Individual; $13,500 Family; with embedded $8,150 individual
OOP limit for family coverage; includes deductible; includes Rx and
MH/SU
$13,500 Individual; $27,000 Family; with embedded $13,500
individual OOP limit for family coverage; includes deductible;
includes Rx and MH/SU; separate from in-network
Primary Doctor Office Visit 80% covered after deductible is met 60% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive
services
60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered after Plan deductible is met 80% covered after Plan deductible is met
• Urgent care clinic visit (facility) 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 60% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 30 visits per year;
combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 10 visits per year;
combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 60% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to $500 per year;
combined in and out-of-network
Effective January – December 2022
18
Anthem BCBS HDHP
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Some preventive Rx not subject to deductible
Retail
• Tier 1 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; some preventive Rx not
subject to deductible; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 2 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; some preventive Rx not
subject to deductible; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 3 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; some preventive Rx not
subject to deductible; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; some preventive Rx not
subject to deductible; check with Plan for details
Reimbursed at contracted rate less applicable copay
Mail Order 80% covered after deductible is met; provides cost savings and
convenience for a 90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible
for non-preventive services; check with Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for
non-preventive services; check w/Plan for preventive sched
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
60% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 60% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for medical svcs; check with Plan
for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1
contraceptives; applicable coinsurance and deductible applies for
other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable coinsurance and deductible
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Rehab: inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 60% cov after ded is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 visits per calendar year;
combined in and out-of-network
• Hospice care 80% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 days per calendar year;
combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
19
Anthem BCBS Premium CMP
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca
This coverage summary provides an overview of benefits available under the Anthem BCBS Premium CMP medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. You may qualify to receive services at discounted rates
when you use Anthem BCBS network providers. For additional information and details about benefits under this medical plan, call the member services department at the
number(s) shown above.
Coverage Highlights Benefits
Annual Deductible
Individual/Family
$650 Individual; $1,950 Family
Out-of-Pocket Maximum
Individual/Family
$2,150 Individual; $6,450 Family; includes deductible and copays; includes MH/SU; Rx excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance
Primary Doctor Office Visit 80% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay $100 copay per admission
Hospital Coinsurance 80% covered after hospital copay and Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) 80% covered after deductible is met
• Urgent care clinic visit (facility) 80% covered after deductible is met
Inpatient Care
• Inpatient surgery 80% covered after hospital copay and Plan deductible is met
• Physician/Surgeon services 80% covered after hospital copay and Plan deductible is met
• Inpatient lab and X-ray services 80% covered after hospital copay and Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met
• Outpatient physical therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient occupational therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient speech therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar year
• Allergy tests and treatments 80% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar year
Effective January – December 2022
20
Anthem BCBS Premium CMP
Coverage Highlights Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Non participating pharmacies: member must submit claim to administrator for reimbursement after paying full out
of pocket cost
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable coinsurance/deductible
• In-hospital doctor's services 80% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000 for
medical services; check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for
other tiers
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Outpatient coverage/visits 80% covered
• Inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered
• Rehab: inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar year
• Hospice care 80% covered after deductible is met
• Prescribed care in a noncustodial skilled nursing facility 80% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 80% covered after deductible is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible expenses are limited to the reasonable and customary (R&C) amount charged for a particular service in a
particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be covered at
all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and exclusions,
contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
21
Anthem BCBS Premium PPO
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)
This coverage summary provides an overview of benefits available under the Anthem BCBS Premium PPO medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network
providers (“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where
services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible
expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s)
shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$650 Individual; $1,950 Family $1,300 Individual; $3,900 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$6,150 Individual; $18,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and
coinsurance
$4,200 Individual; $8,400 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit $20 copay 60% covered after deductible is met
Specialist Office Visit $45 copay; 100% covered for preventive services 60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered for emergency; non-emergency 90%
covered after deductible is met
$200 copay then 90% covered for emergency; non-emergency
60% covered after deductible is met
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist 60% covered after deductible is met
• Outpatient laboratory services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
$20 copay PCP; $45 copay specialist; limited to 30 visits per calendar
year; combined in and out-of-network; coverage may vary based on
place of service
60% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to 10 visits per
calendar year; combined in and out-of-network
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of
service and service performed
60% covered after deductible is met
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
22
Anthem BCBS Premium PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 $40 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 $55 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) $100 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable cost share
60% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met 60% covered after deductible is met
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded inpatient;
limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000
for all medical services; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $20 copay 60% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay 60% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 90% cov after deductible is met; limited to one pair per lifetime 60% cov after ded is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 90% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 90% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
23
Anthem BCBS Standard CMP
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca
This coverage summary provides an overview of benefits available under the Anthem BCBS Standard CMP medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. You may qualify to receive services at discounted rates
when you use Anthem BCBS network providers. For additional information and details about benefits under this medical plan, call the member services department at the
number(s) shown above.
Coverage Highlights Benefits
Annual Deductible
Individual/Family
$1,150 Individual; $3,450 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays; includes MH/SU; Rx excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance
Primary Doctor Office Visit 80% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay $100 copay per admission
Hospital Coinsurance 80% covered after hospital copay and Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) 80% covered after deductible is met
• Urgent care clinic visit (facility) 80% covered after deductible is met
Inpatient Care
• Inpatient surgery 80% covered after hospital copay and Plan deductible is met
• Physician/Surgeon services 80% covered after hospital copay and Plan deductible is met
• Inpatient lab and X-ray services 80% covered after hospital copay and Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met
• Outpatient physical therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient occupational therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Outpatient speech therapy 80% covered after deductible is met; limited to 30 visits per calendar year
• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar year
• Allergy tests and treatments 80% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar year
Effective January – December 2022
24
Anthem BCBS Standard CMP
Coverage Highlights Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Non participating pharmacies: member must submit claim to administrator for reimbursement after paying full out
of pocket cost
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for
preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable coinsurance/deductible
• In-hospital doctor's services 80% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000 for
medical services; check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for
other tiers
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Outpatient coverage/visits 80% covered
• Inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered
• Rehab: inpatient coverage/days $100 copay per admit; then 80% covered; precertification required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar year
• Hospice care 80% covered after deductible is met
• Prescribed care in a noncustodial skilled nursing facility 80% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 80% covered after deductible is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible expenses are limited to the reasonable and customary (R&C) amount charged for a particular service in a
particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be covered at
all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and exclusions,
contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
25
Anthem BCBS Value PPO
Plan Facts
Member services phone number 1-800-364-3301
Hours of operation 5:30 a.m. to 8:00 p.m. PST
Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)
This coverage summary provides an overview of benefits available under the Anthem BCBS Value PPO medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network
providers (“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member
services department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,700 Individual; $5,100 Family $2,500 Individual; $7,500 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$7,250 Individual; $21,750 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 100% cov; up to $250; then 80% cov after ded is met; $250 ann limit
is cmbnd for all office visits
50% covered after deductible is met
Specialist Office Visit 100% covered up to $250; then 80% covered after deductible is
met; 100% covered for preventive services; $250 annual limit is
combined for all office visits
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered for emergency; non-emergency 80%
covered after deductible is met
$200 copay then 90% covered for emergency; non-emergency
50% covered after deductible is met
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 100% covered up to $250; then 80% covered after deductible is
met; $250 annual limit is combined for all office visits
50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 visits per
calendar year; combined in and out-of-network
• Chiropractic services 100% covered; up to $250; then 80% covered after ded; limited to
10 visits per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
100% covered; up to $250; then 80% covered after ded; limited to
10 visits per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
• Allergy tests and treatments 100% cov up to $250 for office visit charges only; other services
80% cov after deductible is met; $250 annual limit is combined for
all office visit services
50% covered after deductible is met
• Acupuncture 100% covered; up to $250; then 80% covered after ded; limited to
$500 per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
100% covered; up to $250; then 80% covered after ded; limited to
$500 per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
Effective January – December 2022
26
Anthem BCBS Value PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 65% covered; $35 min/$75 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 55% covered; $50 min/$105 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $80 min/$140 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 50% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 50% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 50% covered after deductible is met
• Infertility services 80% covered after ded is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for all medical services; check with
Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Rehab: inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime 50% covered after deductible is met; limited to one pair per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 visits per calendar
year; combined in and out-of-network
• Hospice care 80% covered after deductible is met 50% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
27
Blue Essentials HMO
Plan Facts
Member services phone number 1-877-299-2377
Hours of operation 8:00 a.m. to 8:00 p.m. CST
Web site address www.bcbstx.com; network name: Blue Essentials
This coverage summary provides an overview of benefits available under the Blue Essentials HMO medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits under this
medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; medical, mental health copays and coinsurance
included; Rx copays excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes all Rx copays and coinsurance; separate from the medical
out-of-pocket maximum
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care Not covered
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay; then 90% covered
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 100% covered; office visit copay may apply; PCP referral required
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $20 copay PCP; $45 copay specialist
• Outpatient occupational therapy $20 copay PCP; $45 copay specialist
• Outpatient speech therapy $20 copay PCP; $45 copay specialist
• Chiropractic services $45 copay
• Allergy tests and treatments $20 copay PCP; $45 copay specialist
• Acupuncture $45 copay
Effective January – December 2022
28
Blue Essentials HMO
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Tier 1 $10 copay; 30-day supply
• Tier 2 70% cov; $30 min/$60 max; 30-day supply; member will pay the lesser of the cost of drug or minimum copay up to
the maximum copay
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; mbr will pay the lesser of the cost of the drug or min copay
up to the max copay
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay for ED, sleep aids and PPIs; mbr will pay the lesser of the cost of the drug or
min copay up to the max copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs can be filled through any network pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal $20 copay; initial visit only
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met
• Infertility services $20 copay PCP; $45 copay specialist; limited to $10,000 per family per lifetime; $5,000 for Rx and $5,000 for all
medical services; check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for FDA approved contraceptives
Mental Health Care
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered after deductible is met
Vision Care
• Routine eye exams Covered only if part of preventive screening
Hearing Care
• Hearing evaluation test $20 copay PCP; $45 copay specialist; limited to one exam every 36 months; 100% covered for preventive services
• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to 1 pair every 36 months
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 100% covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
29
Cigna CDHP w/HRA
Plan Facts
Member services phone number 1-800-Cigna-24
Hours of operation 24 hours/day; 7 days/week; 365 days/year
Web site address www.cigna.com; network name: Open Access Plus (OAP)
This coverage summary provides an overview of benefits available under the Cigna CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,300 Individual; $3,900 Family $1,950 Individual; $5,850 Family; separate from in-network
Annual HP-Funded Health
Reimbursement Account
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
$500 Individual; $1,000 Family; available to reimburse eligible
expenses; combined in and out-of-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$6,950 Individual; $20,850 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 80% covered after deductible is met 50% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive
services
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered 80% covered
• Urgent care clinic visit (facility) 80% covered 80% covered
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 days per
calendar year; combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 days per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to 10 days per
calendar year; combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 50% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
30
Cigna CDHP w/HRA
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day
supply available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible
for non-preventive services; check with Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for
non-preventive services; chk with Plan for preventive sched
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Infertility services 90% inpatient; 80% outpatient; after deductible is met; limited to
$10,000 per family per lifetime, $5,000 for Rx and $5,000 for medical
svcs; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered 50% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered 50% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to $6,000 per lifetime 50% cov after deductible is met; limited to $6,000 per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Hospice care 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
31
Cigna EPO
Plan Facts
Member services phone number 1-800-Cigna-24
Hours of operation 24 hours/day; 7 days/week; 365 days/year
Web site address www.cigna.com; network name: Open Access Plus (OAP)
This coverage summary provides an overview of benefits available under the Cigna EPO medical plan for the year 2022. Keep in mind that this is only a summary, and does
not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment, coverage may
vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at
90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at
the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,300 Family; includes deductible and copays; includes MH/SU; Rx copays excluded
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay; 100% covered for preventive services
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call
1-855-633-9251
Hospital Copay Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay; then 90% covered
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service
• Outpatient occupational therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service
• Outpatient speech therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 days per calendar year
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of service and service performed
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar year
Effective January – December 2022
32
Cigna EPO
Coverage Highlights In-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Nonparticipating pharmacies not covered (Retail and Mail Order)
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy
• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your
pharmacy
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; limited to one exam per calendar year; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with
Plan for preventive schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with
Plan for preventive schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;
postnatal visits covered at applicable cost share
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified Covered; copay based on location of services
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded is met inpatient; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for all medical services; check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable Rx copay/coinsurance applies for other tiers
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click
“Register” and use the Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule
• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to $6,000 per lifetime
Other Medical Services
• Noncustodial home health care 100% covered; limited to 120 days per calendar year
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 120 days per calendar year
• Durable medical equipment 100% covered; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
33
Cigna HDHP (pre-65 option)
Plan Facts
Member services phone number 1-800-Cigna-24
Hours of operation 24 hours/day; 7 days/week; 365 days/year
Web site address www.cigna.com; network name: Open Access Plus (OAP)
This coverage summary provides an overview of benefits available under the Cigna HDHP medical plan for the year 2022. Keep in mind that this is only a summary, and
does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$2,000 Individual; $4,000 Family $4,000 Individual; $8,000 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$6,750 Individual; $13,500 Family; with embedded $8,150 individual
OOP limit for family coverage; includes deductible; includes Rx and
MH/SU
$13,500 Individual; $27,000 Family; with embedded $13,500
individual OOP limit for family coverage; includes deductible;
includes Rx and MH/SU; separate from in-network
Primary Doctor Office Visit 80% covered after deductible is met 60% covered after deductible is met
Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive
services
60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered after Plan deductible is met 80% covered after Plan deductible is met
• Urgent care clinic visit (facility) 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 80% covered after deductible is met 60% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 30 days per
calendar year; combined in and out-of-network
• Chiropractic services 80% covered after deductible is met; limited to 10 days per calendar
year; combined in and out-of-network
80% covered after deductible is met; limited to 10 days per
calendar year; combined in and out-of-network
• Allergy tests and treatments 80% covered after deductible is met 60% covered after deductible is met
• Acupuncture 80% covered after deductible is met; limited to $500 per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to $500 per year;
combined in and out-of-network
Effective January – December 2022
34
Cigna HDHP
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Some preventive Rx not subject to deductible
Retail
• Tier 1 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 2 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 3 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 80% cov after ded is met; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy; check with Plan for details
Reimbursed at contracted rate less applicable copay
Mail Order 80% covered after deductible is met; provides cost savings and
convenience for a 90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through CVS Specialty Pharmacy Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible
for non-preventive services; check with Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for
non-preventive services; check w/Plan for preventive sched
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
60% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 60% covered after deductible is met
• Infertility services 80% covered after deductible is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for medical svcs; check with Plan
for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order available; 100% covered for Tier 1
contraceptives; applicable coinsurance and deductible applies for
other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable coinsurance and deductible
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met
• Rehab: inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met
• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to $6,000 per lifetime 60% cov after deductible is met; limited to $6,000 per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 days per calendar year;
combined in and out-of-network
• Hospice care 80% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; 120 days per calendar year;
combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
35
Cigna Premium PPO
Plan Facts
Member services phone number 1-800-Cigna-24
Hours of operation 24 hours/day; 7 days/week; 365 days/year
Web site address www.cigna.com; network name: Open Access Plus (OAP)
This coverage summary provides an overview of benefits available under the Cigna Premium PPO medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where services
are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible expenses after
the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$650 Individual; $1,950 Family $1,300 Individual; $3,900 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded
$6,150 Individual; $18,450 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,100 Individual; $4,200 Family; includes Rx copays and
coinsurance
$4,200 Individual; $8,400 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit $20 copay 60% covered after deductible is met
Specialist Office Visit $45 copay; 100% covered for preventive services 60% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered $200 copay then 90% covered
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist 60% covered after deductible is met
• Outpatient laboratory services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met 60% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met 60% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
$20 copay PCP; $45 copay specialist; limited to 30 days per calendar
year; combined in-network and out-of-network; costs may vary
based on place of service
60% covered after deductible is met; limited to 30 days per
calendar year; combined in and out-of-network
• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 days per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to 10 days per
calendar year; combined in and out-of-network
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of
service and service performed
60% covered after deductible is met
• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
$20 copay PCP; $45 copay specialist; limited to $500 per calendar
year; combined in and out-of-network
Effective January – December 2022
36
Cigna Premium PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 $40 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 $55 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) $100 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive care schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay
specialist for non-preventive services; check with Plan for preventive
schedule
60% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable cost share
60% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met 60% covered after deductible is met
• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded inpatient;
limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000
for all medical services; check with Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $20 copay 60% covered
• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $20 copay 60% covered
• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
60% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 90% cov after deductible is met; limited to $6,000 per lifetime 60% cov after deductible is met; limited to $6,000 per lifetime
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Hospice care 90% covered after deductible is met 60% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
90% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
60% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 90% cov after ded is met; repair and maintenance covered 60% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
37
Cigna Value PPO
Plan Facts
Member services phone number 1-800-Cigna-24
Hours of operation 24 hours/day; 7 days/week; 365 days/year
Web site address www.cigna.com; network name: Open Access Plus (OAP)
This coverage summary provides an overview of benefits available under the Cigna Value PPO medical plan for the year 2022. Keep in mind that this is only a summary, and
does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$1,700 Individual; $5,100 Family $2,500 Individual; $7,500 Family; separate from in-network
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $9,450 Family; includes deductible and copays;
includes MH/SUs; Rx copays excluded
$7,250 Individual; $21,750 Family; includes deductible and copays;
includes MH/SU; Rx copays excluded; separate from in-network
Rx Out-of-Pocket Maximum
Individual/Family
$2,300 Individual; $4,600 Family; includes Rx copays and
coinsurance
$4,400 Individual; $8,800 Family; includes Rx copays and
coinsurance
Primary Doctor Office Visit 100% cov; up to $250; then 80% cov after ded is met; $250 ann limit
is cmbnd for all office visits
50% covered after deductible is met
Specialist Office Visit 100% covered up to $250; then 80% covered after deductible is
met; 100% covered for preventive services; $250 annual limit is
combined for all office visits
50% covered after deductible is met
Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
No copay to use HP Health Hub to talk with a provider by phone or
video; visit grandrounds.com/hp or call 1-855-633-9251
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$200 copay then 90% covered $200 copay then 90% covered
• Urgent care clinic visit (facility) $50 copay $50 copay
Inpatient Care
• Inpatient surgery 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Physician/Surgeon services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
• Inpatient lab and X-ray services 80% covered after Plan deductible is met 50% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion 100% covered up to $250; then 80% covered after deductible is
met; $250 annual limit is combined for all office visits
50% covered after deductible is met
• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met
• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met
• Outpatient physical, occupational
and speech therapy
80% covered after deductible is met; limited to 30 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 30 days per
calendar year; combined in and out-of-network
• Chiropractic services 100% covered up to $250, then 80% covered after deductible is
met; limited to 10 days per calendar year; combined in and
out-of-network; $250 annual limit is combined for all office visits
100% covered up to $250, then 80% covered after deductible is
met; limited to 10 days per calendar year; combined in and
out-of-network; $250 annual limit is combined for all office visits
• Allergy tests and treatments 100% covered up to $250 for office visit charges only; other services
80% covered after deductible is met; $250 annual limit is combined
for all office visit services
50% covered after deductible is met
• Acupuncture 100% covered up to $250, then 80% covered after deductible is
met; limited to 10 days per calendar year; combined in and
out-of-network; $250 annual limit is combined for all office visits
100% covered; up to $250; then 80% covered after ded; limited to
$500 per calendar year; combined in and out-of-network; $250
annual limit is combined for all office visits
Effective January – December 2022
38
Cigna Value PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage* Administered by CVS Caremark
Pre-enrollment: Go here to link to the CVS Caremark website
Beginning January 1, 2022: Register at caremark.com
Retail
• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit
caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 2 65% covered; $35 min/$75 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 3 55% covered; $50 min/$105 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
• Tier 4 (ED/sleep aids) 50% covered; $80 min/$140 max; 30-day supply; 90-day supply
available; visit caremark.com or contact your pharmacy
Reimbursed at the contracted rate less applicable copay
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs
in Tiers 1-4 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's
specialty pharmacy)
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services; 1 per calendar year; check with
Plan for preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for preventive services; check with Plan for preventive
schedule
50% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,
then 100% covered for routine prenatal care; postnatal visits covered
at applicable coinsurance/deductible
50% covered after deductible is met
• In-hospital doctor's services 80% covered after deductible is met 50% covered after deductible is met
• Newborn nursery services 80% covered after deductible is met 50% covered after deductible is met
• Midwives, licensed and certified 80% covered after deductible is met 50% covered after deductible is met
• Infertility services 80% covered after ded is met; limited to $10,000 per family per
lifetime, $5,000 for Rx and $5,000 for all medical services; check with
Plan for details
Covered; after ded is met; limited to $10,000 per family per lifetime,
$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;
check with Plan for details
• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable
Rx copay/coinsurance applies for other tiers
Nonparticipating pharmacies reimbursed at contracted rate less
applicable copay/coinsurance
Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
Administered by ComPsych—to find a provider, call 1-844-819-4773,
or login to www.guidanceresources.com, click “Register” and use the
Org Web ID “HP”
• Rehab: outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered
• Rehab: inpatient coverage/days 80% covered; precertification is required 50% covered; precertification is required
Hearing Care
• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for
preventive schedule
50% covered after deductible is met; check with Plan for preventive
schedule
• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to $6,000 per lifetime 50% cov after deductible is met; limited to $6,000 per lifetime
Other Medical Services
• Noncustodial home health care 80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Hospice care 80% covered after deductible is met 50% covered after deductible is met
• Prescribed care in a noncustodial
skilled nursing facility
80% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
50% covered after deductible is met; limited to 120 days per calendar
year; combined in and out-of-network
• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the
brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.
39
HMSA PPO
Plan Facts
Member services phone number 1-800-776-4672
Hours of operation8:00 a.m. to 6:00 p.m.; time varies by location; Hawaii time; hours
may change; visit HMSA.com for updates
Web site address www.hmsa.com
This coverage summary provides an overview of benefits available under the HMSA PPO medical plan for the year 2022. Keep in mind that this is only a summary, and does
not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers (“in-network”)
or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services department at
the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$0 Individual; $0 Family $100 Individual; $300 Family
Out-of-Pocket Maximum
Individual/Family
$2,500 Individual; $7,500 Family; deductible not included; copays
apply; Rx not included
$2,500 Individual; $7,500 Family; includes deductible; copays
apply; Rx not included
Rx Out-of-Pocket Maximum
Individual/Family
$3,600 Individual; $4,200 Family; in and out-of-network combined $3,600 Individual; $4,200 Family; in and out-of-network combined
Primary Doctor Office Visit $12 copay 70% covered after deductible is met
Specialist Office Visit $12 copay 70% covered after deductible is met
Virtual Urgent Care No copay applies; go to hmsa.com to get started Not covered
Hospital Copay Not applicable Not applicable
Hospital Coinsurance 90% covered 70% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
80% covered facility; $12 copay; physician visits; all other services
and supplies see deductible and copay amounts listed
80% covered facility; $12 copay; physician visits; all other services
and supplies see deductible and copay amounts listed
• Urgent care clinic visit (facility) $12 copay 70% covered after deductible is met
Inpatient Care
• Inpatient surgery 90% covered; surgical services; $12 copay per physician visit and
surgeon consultations
70% covered after deductible is met
• Physician/Surgeon services 90% covered; surgical services; $12 copay per physician visit and
surgeon consultations
70% covered after deductible is met
• Inpatient lab and X-ray services 90% covered 70% covered after deductible is met
Outpatient Care
• Second surgical opinion $12 copay 70% covered after deductible is met
• Outpatient laboratory services 80% covered 70% covered after deductible is met
• Outpatient X-ray services 80% covered 70% covered after deductible is met
• Outpatient surgery 90% covered (cutting); 80% covered (non-cutting) 70% covered after deductible is met
• Outpatient physical therapy 80% covered; precertification required after initial visit; maximums
determined by service
70% covered after deductible is met; precertification required after
initial visit; maximums determined by service
• Outpatient occupational therapy 80% covered; precertification required after initial visit; maximums
determined by service
70% covered after deductible is met; precertification required after
initial visit; maximums determined by service
• Outpatient speech therapy 80% covered; certain services subject to precertification; maximums
determined by service
70% covered after deductible is met; certain services subject to
precertification; maximums determined by service
• Chiropractic services Regular Plan benefits apply; check with Plan for details Regular Plan benefits apply; check with Plan for details
• Allergy tests and treatments 80% covered 70% covered after deductible is met
• Acupuncture Not covered Not covered
Effective January – December 2022
40
HMSA PPO
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions. Check with the Plan for exclusions.
Retail
• Generic $7 copay; 30-day supply; Tier 1 (mostly generic drugs) $7 copay; 30-day supply; plus 20% of remaining eligible charge; Tier 1
(mostly generic drugs)
• Formulary $30 copay; 30-day supply; Tier 2 (mostly formulary brand drugs) $30 copay; 30-day supply; plus 20% of remaining eligible charge; Tier
2 (mostly formulary brand drugs)
• Nonformulary $30 copay; 30-day supply; plus $45 Tier 3 cost share (mostly other
brand name drugs)
$30 copay; 30-day supply; plus $45 Tier 3 cost share (mostly other
brand name drugs) and 20% of remaining eligible charge
• ED/sleep aids $100 copay (mostly preferred specialty drugs); check with Plan for
details
Check with Plan for details
Mail Order Covered; provides cost savings and convenience for a 90-day supply
sent direct to your home
Not covered
Specialty Drug Program Check with Plan for details Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services 70% covered after deductible is met
• Well-woman exam (includes pap) 100% covered; routine pap smear limited to once every three years 70% covered after deductible is met; routine pap smear limited to
once every three years
• Mammogram 100% covered; screening 70% covered; screening
• Cancer screenings 100% covered for preventive services; screenings are covered based
on USPSTF grade A and B recommendations
70% covered after deductible is met; screenings are covered based on
USPSTF grade A and B recommendations
Family Planning/Maternity Care
• Office visit: pre/postnatal $12 copay initial visit only; 90% covered for routine prenatal visits,
delivery and one postpartum visit
70% covered after deductible is met; for routine prenatal visits,
delivery and one postpartum visit
• In-hospital doctor's services $12 copay physician services; 90% covered facility 70% covered after deductible is met
• Newborn nursery services 90% covered 70% covered after deductible is met
• Midwives, licensed and certified 90% covered 70% covered after deductible is met; for delivery and midwife services
• Infertility services Covered; limitations apply; precertification is required; check with Plan
for details
Covered; limitations apply; precertification is required; check with Plan
for details
• Oral contraceptives Retail and mail order available; 100% covered for generic oral
contraceptives
Retail available only; regular drug plan benefits
Mental Health Care
• Outpatient coverage/visits 90% covered (facility); $12 copay (physician) 70% covered after deductible is met
• Inpatient coverage/days 90% covered 70% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits 90% covered (facility); $12 copay (physician) 70% covered after deductible is met
• Rehab: inpatient coverage/days 90% covered 70% covered after deductible is met
Vision Care
• Routine eye exams Not covered Not covered
Hearing Care
• Hearing evaluation test Multiple copays may apply; check with Plan for details; limited to
evaluation for use of hearing aids; 100% covered for preventive
services up to age 21
Multiple copays may apply; check with Plan for details; limited to
evaluation for use of hearing aids; 100% covered for preventive
services up to age 21
• Hearing hardware (hearing aid) 80% covered; limited to one device per ear every 60 months 70% covered after deductible is met; limited to one device per ear
every 60 months
Other Medical Services
• Noncustodial home health care 100% covered; limited to 150 visits per calendar year 70% covered after deductible is met; limited to 150 visits per calendar
year
• Hospice care 100% covered Not covered
• Prescribed care in a noncustodial
skilled nursing facility
90% covered; limited to 120 days per calendar year 70% covered after deductible is met; limited to 120 days per calendar
year
• Durable medical equipment 80% covered; preauthorization required 70% covered after deductible is met; preauthorization required
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.
41
Kaiser (Hawaii)
Plan Facts
Member services phone number 1-800-966-5955
Hours of operation 8:00 a.m. to 5:00 p.m.
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser (Hawaii) medical plan for the year 2022. Keep in mind that this is only a summary, and
does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers
(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services
department at the number(s) shown above.
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Annual Deductible
Individual/Family
$0 Individual; $0 Family $100 Individual; $300 Family
Out-of-Pocket Maximum
Individual/Family
$2,000 Individual; $6,000 Family; copays apply $2,000 Individual; $6,000 Family; includes deductible; copays
apply
Primary Doctor Office Visit $15 copay 80% covered after deductible is met
Specialist Office Visit $15 copay 80% covered after deductible is met
Virtual Urgent Care No copay is required; must be an established patient No copay is required; must be an established patient
Hospital Copay $75 copay per day 80% covered after Plan deductible is met
Hospital Coinsurance 100% covered after hospital copay 80% covered after Plan deductible is met
Emergency Care
• Emergency room
(not followed by admission)
$75 copay $75 copay
• Urgent care clinic visit (facility) $15 copay; at a KP facility within the Hawaii service area 80% covered at a non-KP facility outside the Hawaii service area
Inpatient Care
• Inpatient surgery 100% covered after hospital copay 80% covered after Plan deductible is met
• Physician/Surgeon services 100% covered after hospital copay 80% covered after Plan deductible is met
• Inpatient lab and X-ray services 100% covered after hospital copay 80% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $15 copay 80% covered after deductible is met
• Outpatient laboratory services 90% covered 80% covered after deductible is met
• Outpatient X-ray services 90% covered 80% covered after deductible is met
• Outpatient surgery $15 copay 80% covered after deductible is met
• Outpatient physical therapy $15 copay; limited by certain clinical criteria and KP physician
determination; limited to 60 PT/OT/ST visits per calendar year
80% covered after deductible is met; limited to 60 PT/OT/ST visits
per calendar year
• Outpatient occupational therapy $15 copay; limited by certain clinical criteria and KP physician
determination; limited to 60 PT/OT/ST visits per calendar year
80% covered after deductible is met; limited to 60 PT/OT/ST visits
per calendar year
• Outpatient speech therapy $15 copay; limited by certain clinical criteria and KP physician
determination; limited to 60 PT/OT/ST visits per calendar year
80% covered after deductible is met; limited to 60 PT/OT/ST visits
per calendar year
• Chiropractic services Not covered Not covered
• Allergy tests and treatments $15 copay; 90% covered for lab/imaging/testing 80% covered after deductible is met
• Acupuncture Not covered Not covered
Effective January – December 2022
42
Kaiser (Hawaii)
Coverage Highlights In-Network Benefits Out-of-Network Benefits
Prescription Drug Coverage Administered by Kaiser Permanente
Retail
• Generic $10 copay generic; $3 copay generic maintenance; 30-day supply 80% covered; at contracted pharmacies; minimum $10 copay
• Formulary $35 copay; 30-day supply 80% covered; at contracted pharmacies; minimum $35 copay
• Nonformulary $35 copay; $200 copay for specialty drugs; 30-day supply; must be
medically necessary, prescribed by a Plan physician and approved
through the exception process
80% covered; out-of-network; must be medically necessary,
prescribed by a Plan physician and approved through the exception
process
• ED/sleep aids Not covered Not covered
Mail Order 2x the retail 30-day copay for generic and brand name drugs in Tiers
1-3 shown above; provides cost savings and convenience for a 90-day
supply sent direct to your home
Not covered
Specialty Drug Program Specialty drugs must be filled through a designated contracted
pharmacy; check with Plan for details
Not covered
Adult Preventive Care
• Annual physical exam 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive
schedule
• Well-woman exam (includes pap) 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive
schedule
• Mammogram 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive
schedule
• Cancer screenings 100% covered for mammography, cervical cancer screening, FOBT,
colorectal cancer screening, and PSA
80% covered after deductible is met; check with Plan for preventive
schedule
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered; applicable cost share applies for first appointment to
determine pregnancy
80% covered after deductible is met
• In-hospital doctor's services 100% covered after hospital copay 80% covered after deductible is met
• Newborn nursery services 100% covered after hospital copay; provided newborn is added within
31 days of birth
80% covered after deductible is met; provided newborn is added
within 31 days of birth
• Midwives, licensed and certified 100% covered; after confirmation of pregnancy 80% covered after deductible is met
• Infertility services $15 copay for office visits; 80% covered for other services; OOP does
not apply
Not covered
• Oral contraceptives Retail and mail order available; 100% covered for FDA-approved
contraceptives for females of child-bearing age
80% covered, but not less than $10 generic; $35 Brand prescription
for out-of-network contracted pharmacies
Mental Health Care
• Outpatient coverage/visits $15 copay 80% covered after deductible is met
• Inpatient coverage/days $75 copay per day 80% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $15 copay 80% covered after deductible is met
• Rehab: inpatient coverage/days $75 copay per day 80% covered after deductible is met
Vision Care
• Routine eye exams $15 copay; 100% covered for preventive services 80% covered after deductible is met
Hearing Care
• Hearing evaluation test $15 copay; 100% covered for preventive services 80% covered after deductible is met
• Hearing hardware (hearing aid) 40% covered; limited to two aids every three years Not covered
Other Medical Services
• Noncustodial home health care 100% covered; preauthorization required by Kaiser physician; limited
to 150 days per calendar year
80% covered after deductible is met; limited to 150 days per calendar
year
• Hospice care 100% covered; limited to 2, 90 day periods; followed by unlimited 60
day periods
80% covered after deductible is met; limited to 210 days per calendar
year
• Prescribed care in a noncustodial
skilled nursing facility
100% covered; limited to 120 days per calendar year 80% covered after deductible is met; limited to 120 days per calendar
year
• Durable medical equipment 80% covered; 100% covered for internal prosthetics; 50% covered for
diabetes equipment
80% covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular
service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be
covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and
exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical malpractice and other disputes. By enrolling,
you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
43
Kaiser HMO (Colorado)
Plan Facts
Member services phone number 1-800-632-9700
Hours of operation8:00 a.m. to 6:00 p.m.; IVR capabilities available 24 hours a day,
seven days a week for all members, non-members and providers
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Colorado) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including RX copays and coinsurance
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $250 copay after deductible is met
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met; 100% covered for preventive services
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state
mandate
• Outpatient occupational therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state
mandate
• Outpatient speech therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state
mandate
• Chiropractic services $20 copay; limited to 30 visits per calendar year
• Allergy tests and treatments Copay for testing varies based on place of service; $20 or $45 copay; $20 copay for injections
• Acupuncture 25% discount available through participating providers
Effective January – December 2022
44
Kaiser HMO (Colorado)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Tier 1 $10 copay; 30-day supply; sexual dysfunction drugs excluded
• Tier 2 70% covered; $30 min/$60 max; 30-day supply; sexual dysfunction drugs excluded
• Tier 3 60% covered; $45 minimum copay; $75 maximum copay; 30 day supply
• Tier 4 (ED/sleep aids) 50% covered; $50 minimum copay; $100 maximum copay; 30-day supply; for sleep aids, erectile dysfunction and
proton pump inhibitors
Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost
savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services; $45 specialist copay for subsequent GYN visits
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal 90% covered after deductible is met
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met; charges apply under mother's coverage
• Midwives, licensed and certified Not covered
• Infertility services 50% covered; deductible does not apply; drugs not covered
• Oral contraceptives Retail and mail order available; 100% covered; for FDA approved services
Mental Health Care
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered after deductible is met
Vision Care
• Routine eye exams $20 copay; 100% covered for child screenings
Hearing Care
• Hearing evaluation test $20 copay; 100% covered for newborn screenings
• Hearing hardware (hearing aid) Not covered
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met
• Hospice care 100% covered; not subject to deductible
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 90% covered; deductible applies for supplemental DME
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
45
Kaiser HMO (Georgia)
Plan Facts
Member services phone number 1-888-865-5813
Hours of operation 7:00 a.m. to 7:00 p.m.
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Georgia) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including RX copays and coinsurance
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay
• Urgent care clinic visit (facility) $50 copay; at designated facilities
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $45 copay if second opinion is provided by a Plan physician; otherwise not covered
• Outpatient laboratory services 90% covered after deductible is met; routine lab in office 100% covered; after applicable office visit copay
• Outpatient X-ray services 90% covered after deductible is met; routine x-ray in office 100% covered; after applicable office visit copay
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay; limited to 20 visits per calendar year; combined with occupational therapy
• Outpatient occupational therapy $45 copay; limited to 20 visits per calendar year; combined with physical therapy
• Outpatient speech therapy $45 copay; limited to 20 visits per calendar year
• Chiropractic services $20 copay; limited to 20 visits per calendar year
• Allergy tests and treatments 90% for covered tests; $20 copay PCP; $45 copay specialist for injection; serum covered under office visit
copay
• Acupuncture Not covered
Effective January – December 2022
46
Kaiser HMO (Georgia)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Generic $10 copay; 30-day supply; $20 copay at network pharmacies; network pharmacies limited to a one-time fill per
medication
• Formulary 70% covered; $60 maximum copay; 30-day supply; net difference; network pharmacies limited to a one-time fill per
medication
• Nonformulary 60% covered; $75 maximum copay; 30-day supply; net difference; network pharmacies limited to a one-time fill per
medication
• ED/sleep aids Not covered
Mail Order $20 copay generic from KP pharmacy only; 2x the retail 30-day copay for brand name drugs in Tiers 2-3 shown
above; provides cost savings and convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal 90% covered after deductible is met; office visit copay may apply depending on place of service; routine pre-natal
visits and first post-natal visit covered 100%
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met
• Infertility services 90% covered after deductible is met; for diagnosis; 50% covered treatment within Plan guidelines
• Oral contraceptives Retail and mail order available; 100% covered
Mental Health Care
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered after deductible is met
Vision Care
• Routine eye exams $45 copay at Plan providers; 100% covered for preventive services
Hearing Care
• Hearing evaluation test $20 copay PCP; $45 copay specialist; limited to screening only; 100% covered for preventive services
• Hearing hardware (hearing aid) Not covered
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met; limited to 120 visits per calendar year; private duty nursing not covered
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 60 days per calendar year
• Durable medical equipment 100% covered; prosthetics and orthotics covered separately than DME; check with Plan for details
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
47
Kaiser HMO (Hawaii) (pre-65 option)
Plan Facts
Member services phone number 1-800-966-5955
Hours of operation 8:00 a.m. to 5:00 p.m.
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Hawaii) medical plan for the year 2022. Keep in mind that this is only a summary,
and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits under this
medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$0 Individual; $0 Family
Out-of-Pocket Maximum
Individual/Family
$2,000 Individual; $6,000 Family; copays apply
Primary Doctor Office Visit $15 copay; 100% covered age 0 - 17 years
Specialist Office Visit $15 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay $50 copay per day
Hospital Coinsurance 100% covered after hospital copay
Emergency Care
• Emergency room (not followed by admission) $50 copay
• Urgent care clinic visit (facility) $15 copay; at a KP facility within the Hawaii service area; 80% covered outside of service area
Inpatient Care
• Inpatient surgery 100% covered after hospital copay
• Physician/Surgeon services 100% covered after hospital copay
• Inpatient lab and X-ray services 100% covered after hospital copay
Outpatient Care
• Second surgical opinion $15 copay
• Outpatient laboratory services 90% covered
• Outpatient X-ray services 90% covered
• Outpatient surgery $15 copay
• Outpatient physical therapy $15 copay; limited by certain clinical criteria and KP physician determination
• Outpatient occupational therapy $15 copay; limited by certain clinical criteria and KP physician determination
• Outpatient speech therapy $15 copay; limited by certain clinical criteria and KP physician determination
• Chiropractic services Not covered
• Allergy tests and treatments $15 copay; 80% covered when administered by skilled personnel
• Acupuncture Not covered
Effective January – December 2022
48
Kaiser HMO (Hawaii)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Administered by Kaiser Permanente
Retail
• Generic $10 copay generic; $3 copay generic maintenance; 30-day supply
• Formulary $35 copay; 30-day supply
• Nonformulary $35 copay; 30-day supply; must be medically necessary, prescribed by a Plan physician and approved through the
exception process
• ED/sleep aids Not covered
Mail Order 2x the retail 30-day copay for generic and brand name drugs in Tiers 1-3 shown above; provides cost savings and
convenience for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for mammography, cervical cancer screening, FOBT, colorectal cancer screening, and PSA
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered; applicable cost share applies for first appointment to determine pregnancy
• In-hospital doctor's services 100% covered after hospital copay
• Newborn nursery services 100% covered after hospital copay; provided newborn is added within 31 days of birth
• Midwives, licensed and certified $15 copay; only Kaiser Permanente contracted midwives are covered
• Infertility services $15 copay for office visits; 80% covered for other services; limited to 1 cycle per lifetime
• Oral contraceptives Retail and mail order available; 100% covered for FDA-approved contraceptives for females of child-bearing age
Mental Health Care
• Outpatient coverage/visits $15 copay
• Inpatient coverage/days $50 copay per day
Substance Use Disorder
• Rehab: outpatient coverage/visits $15 copay
• Rehab: inpatient coverage/days $50 copay per day
Vision Care
• Routine eye exams $15 copay
Hearing Care
• Hearing evaluation test $15 copay; 100% covered for preventive services for children
• Hearing hardware (hearing aid) 40% covered; limited to two aids every three years
Other Medical Services
• Noncustodial home health care 100% covered
• Hospice care 100% covered
• Prescribed care in a noncustodial skilled nursing facility 100% covered
• Durable medical equipment 80% covered; 50% covered for diabetes equipment
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
49
Kaiser HMO (Mid-Atlantic)
Plan Facts
Member services phone number 1-800-777-7902
Hours of operation 7:30 a.m. to 5:30 p.m. EST
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Mid-Atlantic) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including Rx copays
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay
• Urgent care clinic visit (facility) $50 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $45 copay
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay; limited to 30 visits per condition
• Outpatient occupational therapy $45 copay; limited to 30 visits per incident
• Outpatient speech therapy $45 copay; limited to 30 visits per incident
• Chiropractic services $45 copay; limited to 40 visits per calendar year
• Allergy tests and treatments $20 copay PCP; $45 copay specialist
• Acupuncture $45 copay; limited to 40 visits per calendar year
Effective January – December 2022
50
Kaiser HMO (Mid-Atlantic)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Generic $10 copay; 30-day supply; Community Pharmacy $20 copay
• Formulary $30 copay; 30-day supply; Community Pharmacy $60 copay
• Nonformulary $45 copay; 30-day supply; Community Pharmacy $75 copay
• ED/sleep aids Not covered
Mail Order 2x the retail 30-day copay for brand name drugs in Tiers 1-3 shown above; provides cost savings and convenience
for a 90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a KP Mail Order; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered; $45 initial visit copay
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met
• Infertility services 50% covered after deductible is met
• Oral contraceptives Retail and mail order available; 100% covered
Mental Health Care
• Outpatient coverage/visits $20 copay individual visit; $10 copay group visit
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay individual visit; $10 copay group visit
• Rehab: inpatient coverage/days 90% covered after deductible is met
Vision Care
• Routine eye exams Covered only if part of a preventive screening
Hearing Care
• Hearing evaluation test $20 copay PCP; $45 copay specialist; 100% covered for children up to age 5
• Hearing hardware (hearing aid) State mandates cover children; limited to age 18; limited to 1 hearing aid per ear every 36 months or $1,000
maximum
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met
• Hospice care 90% covered after deductible is met
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 100% covered
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
51
Kaiser HMO (NorthWest)
Plan Facts
Member services phone number 1-800-813-2000
Hours of operation 8:00 a.m. to 6:00 p.m.
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (NorthWest) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including Rx copays
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay after deductible is met
• Urgent care clinic visit (facility) $50 copay; at Plan facility or out-of-area non-Plan facility; emergency room copay applies for treatment
received at hospital emergency department
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $45 copay
• Outpatient laboratory services 90% covered after deductible is met
• Outpatient X-ray services 90% covered after deductible is met
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year
• Outpatient occupational therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year
• Outpatient speech therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year
• Chiropractic services $20 copay; limited to 20 visits per calendar year
• Allergy tests and treatments $45 copay for tests; $10 copay per injection
• Acupuncture Not covered for self-referred acupuncture; $45 copay for physician-referred acupuncture; limited to 12 visits
per calendar year
Effective January – December 2022
52
Kaiser HMO (NorthWest)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Generic $5 copay; 30-day supply
• Formulary $30 copay; 30-day supply; brand drugs
• Nonformulary $45 copay; 30-day supply
• ED/sleep aids Not covered
Mail Order 2x the retail copay for brand name drugs in Tiers 1-3 shown above; provides cost savings and convenience for a
90-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services; for office visit and/or lab
• Mammogram 100% covered for preventive services
• Cancer screenings 100% covered for preventive services; for x-ray and laboratory services
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met
• Midwives, licensed and certified 90% covered after deductible is met; must use participating provider
• Infertility services 50% covered after deductible is met; diagnosis and treatment
• Oral contraceptives Retail and mail order available; 100% covered
Mental Health Care
• Outpatient coverage/visits $20 copay
• Inpatient coverage/days 90% covered after deductible is met; residential care same as hospital inpatient benefit
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay
• Rehab: inpatient coverage/days 90% covered after deductible is met
Vision Care
• Routine eye exams $20 copay per exam; 100% covered for preventive services
Hearing Care
• Hearing evaluation test $20 copay; 100% covered for preventive services; $45 copay for Audiologist
• Hearing hardware (hearing aid) Not covered
Other Medical Services
• Noncustodial home health care 90% covered after deductible is met; for homebound patient in the service area upon physician referral; limited to
130 days per calendar year
• Hospice care 100% covered for patient diagnosed with life expectancy of six months or less
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 100% covered; Medicare criteria applies
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
53
Kaiser HMO (Northern CA)
Plan Facts
Member services phone number 1-800-464-4000
Hours of operation
24/7; Member Services will close at 10:00 p.m. on the Eve of and
reopen at 4:00 a.m. the day after the following holidays: New Year's
Day, Fourth of July, Memorial Day, Thanksgiving Day, Christmas Day
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Northern CA) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including Rx copays
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay
• Urgent care clinic visit (facility) $20 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met; per encounter; 100% covered for preventive screening labs
• Outpatient X-ray services 90% covered after deductible is met; per encounter for diagnostic x-ray; 100% covered for preventive
screening; 90% covered for high-cost radiology; deductible does not apply to high-cost radiology
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician
• Outpatient occupational therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by a Plan physician
• Outpatient speech therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician
• Chiropractic services $15 copay; limited to 30 visits per calendar year; limited to $50 per calendar year allowance toward the
purchase of appliances
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; allergy injections 100% covered
• Acupuncture $45 copay; covered as alternative to standard treatment when, in the judgment of a Plan Dr., it is the most
appropriate treatment for the spec cndtn of the patient
Effective January – December 2022
54
Kaiser HMO (Northern CA)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Generic $10 copay; 30-day supply
• Formulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies
• Nonformulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies; must be approved through an exception process
• ED/sleep aids $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies
Mail Order 2x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost savings and convenience
for a 100-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive screening & imaging
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered per scheduled prenatal visits and 1st postpartum visit; $20 copay PCP; $45 copay specialist for
diagnostic visits; 90% covered after deductible is met for diagnostic labs
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met; during mother's hospitalization; charges apply under mother's coverage
• Midwives, licensed and certified 90% covered after deductible is met; only at Plan facilities where available
• Infertility services 50% covered; for diagnosis/trtmnt of involuntary infertility when preauthorized by Plan physician; inpat care/outpat
surgery subject to deductible
• Oral contraceptives Retail and mail order available; 100% covered if used for contraceptive purposes; applicable Rx copays apply if not
used for contraceptive purposes
Mental Health Care
• Outpatient coverage/visits $20 copay individual visit; $10 copay group visit
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay individual visit; $5 copay group visit
• Rehab: inpatient coverage/days 90% covered after deductible is met; $100 copay per admit after deductible for Transitional Residential Recovery
Service (TRRS) in a non-medical setting
Vision Care
• Routine eye exams 100% covered for preventive services and refraction; $20 copay PCP; $45 copay specialist for diagnostic services
Hearing Care
• Hearing evaluation test 100% covered for preventive services; $20 copay PCP; $45 copay specialist visit for diagnostic services
• Hearing hardware (hearing aid) Not covered
Other Medical Services
• Noncustodial home health care 100% covered; must be prescribed by a Plan physician and provided within the service area; limited to 3 visits per
day & 100 visits per calendar year
• Hospice care 100% covered; within the service area when selected as an alternative to traditional services; check with Plan for
eligibility requirements
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 100% covered; per item when deemed medically necessary and prescribed by a Plan physician in accordance with
DME formulary guidelines
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.
55
Kaiser HMO (Southern CA)
Plan Facts
Member services phone number 1-800-464-4000
Hours of operation
24/7; Member Services will close at 10:00 p.m. on the Eve of and
reopen at 4:00 a.m. the day after the following holidays: New Year's
Day, Fourth of July, Memorial Day, Thanksgiving Day, Christmas Day
Web site address https://my.kp.org/hp/
This coverage summary provides an overview of benefits available under the Kaiser HMO (Southern CA) medical plan for the year 2022. Keep in mind that this is only a
summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits
under this medical plan, call the member services department at the number(s) shown above.
Coverage Highlights In-Network Benefits
Annual Deductible
Individual/Family
$600 Individual; $1,200 Family
Out-of-Pocket Maximum
Individual/Family
$3,150 Individual; $6,150 Family; includes deductible; copays apply; including Rx copays
Primary Doctor Office Visit $20 copay
Specialist Office Visit $45 copay
Virtual Urgent Care No copay is required; must be an established patient
Hospital Copay Not applicable; coinsurance and deductible apply
Hospital Coinsurance 90% covered after Plan deductible is met
Emergency Care
• Emergency room (not followed by admission) $200 copay
• Urgent care clinic visit (facility) $20 copay
Inpatient Care
• Inpatient surgery 90% covered after Plan deductible is met
• Physician/Surgeon services 90% covered after Plan deductible is met
• Inpatient lab and X-ray services 90% covered after Plan deductible is met
Outpatient Care
• Second surgical opinion $20 copay PCP; $45 copay specialist
• Outpatient laboratory services 90% covered after deductible is met; per encounter; 100% covered for preventive screening labs
• Outpatient X-ray services 90% covered after deductible is met; per encounter for diagnostic x-ray; 100% covered for preventive
screening; 90% covered for high-cost radiology; deductible does not apply to high-cost radiology
• Outpatient surgery 90% covered after deductible is met
• Outpatient physical therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician
• Outpatient occupational therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by a Plan physician
• Outpatient speech therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician
• Chiropractic services $15 copay; limited to 30 visits per calendar year; limited to $50 per calendar year allowance toward the
purchase of appliances
• Allergy tests and treatments $20 copay PCP; $45 copay specialist; allergy injections 100% covered
• Acupuncture $45 copay; covered as alternative to standard treatment when, in the judgment of a Plan Dr., it is the most
appropriate treatment for the spec cndtn of the patient
Effective January – December 2022
56
Kaiser HMO (Southern CA)
Coverage Highlights In-Network Benefits
Prescription Drug Coverage Check with the Plan for exclusions.
Retail
• Generic $10 copay; 30-day supply
• Formulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies
• Nonformulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies; must be approved through an exception process
• ED/sleep aids $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan
pharmacies
Mail Order 2x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost savings and convenience
for a 100-day supply sent direct to your home
Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details
Adult Preventive Care
• Annual physical exam 100% covered for preventive services
• Well-woman exam (includes pap) 100% covered for preventive services
• Mammogram 100% covered for preventive screening & imaging
• Cancer screenings 100% covered for preventive services
Family Planning/Maternity Care
• Office visit: pre/postnatal 100% covered per scheduled prenatal visits and 1st postpartum visit; $20 copay PCP; $45 copay specialist for
diagnostic visits; 90% covered after deductible is met for diagnostic labs
• In-hospital doctor's services 90% covered after deductible is met
• Newborn nursery services 90% covered after deductible is met; during mother's hospitalization; charges apply under mother's coverage
• Midwives, licensed and certified 90% covered after deductible is met; only at Plan facilities where available
• Infertility services 50% covered; for diagnosis/trtmnt of involuntary infertility when preauthorized by Plan physician; inpat care/outpat
surgery subject to deductible
• Oral contraceptives Retail and mail order available; 100% covered if used for contraceptive purposes; applicable Rx copays apply if not
used for contraceptive purposes
Mental Health Care
• Outpatient coverage/visits $20 copay individual visit; $10 copay group visit
• Inpatient coverage/days 90% covered after deductible is met
Substance Use Disorder
• Rehab: outpatient coverage/visits $20 copay individual visit; $5 copay group visit
• Rehab: inpatient coverage/days 90% covered after deductible is met; $100 copay per admit after deductible for Transitional Residential Recovery
Service (TRRS) in a non-medical setting
Vision Care
• Routine eye exams 100% covered for preventive services and refraction; $20 copay PCP; $45 copay specialist for diagnostic services
Hearing Care
• Hearing evaluation test 100% covered for preventive services; $20 copay PCP; $45 copay specialist visit for diagnostic services
• Hearing hardware (hearing aid) Not covered
Other Medical Services
• Noncustodial home health care 100% covered; must be prescribed by a Plan physician and provided within the service area; limited to 3 visits per
day & 100 visits per calendar year
• Hospice care 100% covered; within the service area when selected as an alternative to traditional services; check with Plan for
eligibility requirements
• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 100 days per calendar year
• Durable medical equipment 100% covered; per item when deemed medically necessary and prescribed by a Plan physician in accordance with
DME formulary guidelines
Special Messages
All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be
different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For
information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical
malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.