| Benefits |
Kaiser Permanente |
 Sutter Health Plus |
Blue Shield Preferred |
|---|---|---|---|
| Service Areas | Within the KP footprint | Within the SHPlus footprint | Any State |
| Annual Deductible | $5,500/11,000 (You pay $0) | $5,500/$11,000 (You pay $0) |
|
| Max Copay | $6550/$13,100 (You only pay the final $1,050/$2,100) |
$6,500/13,000 (You only pay the final $1,000/$2,000) |
|
| Preventative Health | |||
| Annual Routine Exam | No Charge | No Charge | No Charge |
| Well Woman Exam | No Charge | No Charge | No Charge |
| Well Child Preventative Care | No Charge | No Charge | No Charge |
| Outpatient Services | |||
| Office Visits | $20 per visit | $50 per visit | 20% per visit |
| Labs and X-Rays | $10 per encounter | No Charge | 20% per visit |
| Hospital Services | |||
| Inpatient | 20% per admit | 30% coinsurance after deductible | 20% per admit |
| Outpatient Surgery | 20% per procedure | 30% coinsurance after deductible | 20% per procedure |
| Outpatient Services | 20% per procedure | 30% coinsurance after deductible | 20% per procedure |
| CT Scans, MRIs, MRAs, PET Scans | 20%per procedure | $100 copay per procedure after deductible | $100 per visit + 20% |
| Skilled Nursing Facility | 20% per admit | 30% after deductible | 20% per admit |
| Prescription Medications 30 day supply | |||
| Retail Generic | $10 | $10 | $10 |
| Retail Formulary Brand | $30 | $30 | $25 |
| Non-Formulary Brand | N/A | $60 | $40 |
| Specialty Drugs | $250 | 30% coinsurance up to $250 | $250 |
| Prescription Medications Mail Order 100-days | |||
| Mail Order Generic | $20 | $20 | $20 |
| Mail Order Formulary Brand | $50 | $60 | $50 |
| Mail Order Non-Formulary | N/A | $ 120 | $80 |
| Emergency Services | |||
| ER Visit | $100 per visit | $150 per visit | $100 per visit |
| Ambulance Transport | $150 per trip | $150 copay per trip after deductible | 20% per trip |
| Short Term Rehab Services | 20% per visit | $50 [er visit | 20% per visit |
| Mental Health Services Blue Shield uses MHSA- Magellen Assist | |||
| Inpatient Care | 20% per admit | $50 per visit | 100% per admit + 20% |
| Outpatient Individual Therapy | $20 per visit | $50 per visit/$20 per telehealth visit | 20% per visit |
| Chemical Dependency Services | |||
| Inpatient Detox | 20% per admit | 30% coinsurance after deductible | Not Covered |
| Outpatient Individual Therapy | $20 per visit | $50 per visit/$20 per telehealth visit | Not Covered |
| Chiropractic and Acupuncture | |||
| Chiropractic | $0 (30 sessions through Landmark Healthplan) | $0 (30 sessions through Landmark Healthplan) | 20% per visit |
| Chiropractic | $0 (30 sessions through Landmark Healthplan) | $0 (30 sessions through Landmark Healthplan) | 20% per visit |
Highlighted cells are not included in the copay exclusion
