| Benefits |
Kaiser Permanente |
Sutter Health Plus with HRA |
Blue Shield Preferred In Network |
Blue Shield Preferred Out of Network |
|---|---|---|---|---|
| Service Areas | Within the KP footprint | Within the SHPlus footprint | Any State |
Any State |
| Annual Deductible | $5,500/11,000 (You pay $0) | $5,500/$11,000 (You pay $0) |
$2500/$5,000 | $2500/$5,000 |
| /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) |
$6850/$13,700 | $10,500/$21,000 |
| $10,500/$21,000Preventative Health | ||||
| Annual Routine Exam | No Charge | No Charge | No Charge | Not Covered |
| Well Woman Exam | No Charge | No Charge | No Charge | Not Covered |
| Well Child Preventative Care | No Charge | No Charge | 20% | 50% |
| Outpatient Services | ||||
| Office Visits | $20 per visit | $50 per visit | $25 per visit | 50% |
| Labs and X-Rays | $10 per encounter | No Charge | $25 per visit | 50% |
| Hospital Services | ||||
| Inpatient | 20% per admit | 30% coinsurance after deductible | 20% per admit | 50% of up to $600/day plus 100% of additional charges |
| Outpatient Surgery | 20% per procedure | 30% coinsurance after deductible |
Ambulatory Center:10% Outpatient Dept of Hospital: 25% |
50% of up to $350/day plus 100% of additional charges |
| Outpatient Services | 20% per procedure | 30% coinsurance after deductible | 20% per procedure | 50% of up to $350/day plus 100% of additional charges |
| CT Scans, MRIs, MRAs, PET Scans | 20%per procedure | $100 copay per procedure after deductible | $100 per visit + 20% | 50% of up to $350/day plus 100% of additional charges |
| Skilled Nursing Facility | 20% per admit | 30% after deductible | 20% per admit | 50% |
| Prescription Medications 30 day supply | ||||
| Retail Generic | $10 | $10 | $15 | 25% plus $15 per Rx |
| Retail Formulary Brand | $30 | $30 | $30 | 25% plus $30 per Rx |
| Non-Formulary Brand | N/A | $60 | $45 | 25% plus $45 per Rx |
| Specialty Drugs | $250 | 30% coinsurance up to $250 | 25% plus $15 per Rx | 25% plus $15 per Rx plus 25% of purchase price |
| Prescription Medications Mail Order 100-days | ||||
| Mail Order Generic | $20 | $20 | $20 | Not Covered |
| Mail Order Formulary Brand | $50 | $60 | $50 | Not Covered |
| Mail Order Non-Formulary | N/A | $ 120 | $80 | Not Covered |
| Emergency Services | ||||
| ER Visit | $100 per visit | $150 per visit | $150 per visit plus 20% | $150 per visit plus 20% |
| Ambulance Transport | $150 per trip | $150 copay per trip after deductible | 20% per trip | 20% |
| Short Term Rehab Services | 20% per visit | $50 [er visit | 20% | 25% |
| Mental Health Services Blue Shield uses MHSA- Magellen Assist | ||||
| Inpatient Care | 20% per admit | $50 per visit | $25 per visit | 50% |
| Outpatient Individual Therapy | $20 per visit | $50 per visit/$20 per telehealth visit | $25 per visit | 50% |
| Chemical Dependency Services | ||||
| Inpatient Detox | 20% per admit | 30% coinsurance after deductible | 0-20% | 50% |
| Outpatient Individual Therapy | $20 per visit | $50 per visit/$20 per telehealth visit | $0 - $25 per visit | 50% |
| Chiropractic and Acupuncture | ||||
| Chiropractic | $0 (30 sessions through Landmark Healthplan) | $0 (30 sessions through Landmark Healthplan) | $25 per visit | 50% |
| Chiropractic | $0 (30 sessions through Landmark Healthplan) | $0 (30 sessions through Landmark Healthplan) | $25 per visit | 50% |
Highlighted cells are not included in the copay exclusion
