Medical Plan Summary of Benefits Chart
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC.
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC. EOCs are available for download at sfhss.org.
| medical plans | ||||||
|---|---|---|---|---|---|---|
| HEALTH NET | KAISER PERMANENTE | BLUE SHIELD OF CALIFORNIA | ||||
CANOPYCARE HMO | TRADITIONAL HMO | TRIO HMO | ACCESS+ HMO | BLUE SHIELD OF CALIFORNIA PPO | ||
Choice of Physician | PCP assignment required. | KP network only. PCP assignment required. | PCP assignment required. | You may use any licensed provider. You receive a higher level of benefit and pay lower out-of-pocket costs when choosing in-network providers. | ||
| Deductible | No deductible | No deductible | No deductible | IN-NETWORK AND OUT-OF-AREA | OUT-OF-NETWORK | |
$250 employee only $500 +1 $750 +2 or more | $500 employee only $1,000 +1 $1,500 +2 or more | |||||
| General Care and Urgent Care | ||||||
Annual Physical; Well Woman Exam | No charge | No charge | No charge | 100% covered no deductible | 50% covered after deductible | |
| Doctor Office Visit | $25 co-pay | $20 co-pay | $25 co-pay | 85% covered after deductible | 50% covered after deductible | |
| Urgent Care Visit | $25 co-pay in-network and out-of-network | $20 co-pay | $25 co-pay in-network | 85% covered after deductible | 50% covered after deductible | |
| Family Planning | No charge | No charge | No charge | 100% covered no deductible | 50% covered after deductible | |
| Immunizations | No charge | No charge | No charge | 100% covered no deductible | 100% covered no deductible | |
| Lab and X-ray | No charge | No charge | No charge | 85% covered after deductible & prior notification | 50% covered after deductible & prior notification | |
| Doctor’s Hospital Visit | No charge | No charge | No charge | 85% covered after deductible | 50% covered after deductible | |
| Prescription Drugs | ||||||
| Pharmacy: Generic | $10 co-pay 30-day supply | $5 co-pay 30-day supply | $10 co-pay 30-day supply | $10 co-pay 30-day supply | $10 co-pay plus 50% Coinsurance; 30-day supply | |
Pharmacy: Brand-Name | $25 co-pay 30-day supply | $15 co-pay 30-day supply | $25 co-pay 30-day supply | $25 co-pay 30-day supply | $25 co-pay plus 50% Coinsurance; 30-day supply | |
Pharmacy: Non-Formulary | $50 co-pay 30-day supply | Only if authorized by a Kaiser Physician | $50 co-pay 30-day supply | $50 co-pay 30-day supply | $50 co-pay, plus 50% Coinsurance; 30-day supply | |
| Mail Order: Generic | $20 co-pay 90-day supply | $10 co-pay 100-day supply | $20 co-pay 90-day supply | $20 co-pay 90-day supply | Not covered | |
Mail Order: Brand-Name | $50 co-pay 90-day supply | $30 co-pay 100-day supply | $50 co-pay 90-day supply | $50 co-pay 90-day supply | Not covered | |
Mail Order: Non-Formulary | $100 co-pay 90-day supply | Only if authorized by a Kaiser Physician | $100 co-pay 90-day supply | $100 co-pay 90-day supply | Not covered | |
| Specialty | 20% up to $100 co-pay; 30-day supply | 20% up to $100 co-pay; 30-day supply | 20% up to $100 co-pay; 30-day supply | $50 co-pay 30-day supply | $50 co-pay, plus 50% Coinsurance; 30-day supply | |
| Hospital Outpatient and Inpatient | ||||||
Hospital Outpatient | $100 co-pay per surgery | $35 co-pay | $100 co-pay per surgery | 85% covered after deductible | 50% covered after deductible | |
Hospital Inpatient | $200 co-pay per admission | $100 co-pay per admission | $200 co-pay per admission | 85% covered after deduct- ible; may require prior notification | 50% covered after deductible; may require prior notification | |
Hospital Emergency Room | $100 co-pay waived if hospitalized | $100 co-pay waived if hospitalized | $100 co-pay waived if hospitalized | 85% covered after deductible if non-emergency, 50% after deductible | 85% covered after deductible if non-emergency, 50% after deductible | |
Skilled Nursing Facility | No charge 100 days per plan year | No charge 100 days per benefit period | No charge 100 days per plan year | 85% covered after deductible; 120 days per plan year; limits apply | 50% covered after deductible; 120 days per plan year; limits apply | |
| Hospice | No charge authorization req. | No charge when medically necessary | No charge authoriza- tion required | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |
| Maternity and Infertility | ||||||
Hospital or Birthing Center | $200 co-pay per admission | $100 co-pay per admission | $200 co-pay per admission | 85% covered after deductible; may require prior notification | 50% covered after deductible; may require prior notification | |
Pre-/Post-Partum Care | No charge | No charge | No charge | 85% covered after deductible | 50% covered after deductible | |
| Well Child Care | No charge must enroll newborn within 30 days of birth; see EOC | No charge must enroll newborn within 30 days of birth; see EOC | No charge must enroll newborn within 30 days of birth; see EOC | 100% covered no deductible | 100% covered no deductible | |
IVF, GIFT, ZIFT and Artificial Insemination | Co-pays apply; authorization required | Co-pays apply; authorization required | Co-pays apply; authorization required | 85% covered after deductible; limitations apply; prior notification | 50% covered after deductible; limitations apply; prior notification | |
| Mental Health and Substance Abuse Services | ||||||
Outpatient Treatment | $25 co-pay non-severe and severe | $10 co-pay group $20 co-pay individual | $25 co-pay non-severe and severe | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |
Inpatient Facility (Including detox and residential rehab) | $200 co-pay per admission | $100 co-pay per admission | $200 co-pay per admission | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |
| Other | ||||||
| Hearing Aids (1 aid per ear every 36 months; no charge for evaluation) | Up to $5,000, combined for both ears, every 36 months; no charge for evaluation | Up to $2,500 per ear, every 36 months; no evaluation charge | Up to $2,500 per ear, every 36 months; no charge for evaluation | 85% covered after deductible; up to $2,500 per ear, every 36 months | 50% covered after deductible; up to $2,500 per ear, every 36 months | |
Medical Equipment, Prosthetics and Orthotics | No charge as authorized by PCP | No charge as authorized by PCP | No charge as authorized by PCP | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |
Medical Equipment, Prosthetics and Orthotics | No charge as authorized by PCP | No charge as authorized by PCP | No charge as authorized by PCP | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |
Physical and Occupational Therapy | $25 co-pay | $20 co-pay authorization required | $25 co-pay | 85% covered after deductible; limitations may apply, see EOC | 50% covered after deductible; limitations may apply, see EOC | |
Acupuncture/ Chiropractic | $15 co-pay 30 visits max for each per plan year; ASH network | $15 co-pay up to a combined total of 30 chiropractic and acupuncture visits/ year; ASH network | $15 co-pay 30 visits max for each per plan year; ASH network | 50% covered after deductible; $1,000 max per plan year | 50% covered after deductible; $1,000 max per plan year | |
Gender Dysphoria (Office visits and outpatient surgery) | Co-pays apply; authorization required | Co-pays apply; authorization required | Co-pays apply; authorization required | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | |