Medical Plan Comparison Charts
View side by side comparisons of the CHP EPO and PPO, Traditional HMO, Hospital Services DHMO, Deductible First HDHP and Retiree Medicare plans. The benefits listed are effective for the plan year June 1, 2026 - May 31, 2027.
Employee Semi-Monthly Medical Premiums
Extra Help Semi-Monthly Medical Premiums
Retriee Monthly Medical Premiums
County Health Plan EPO and PPO
Deductible and Out of Pocket Maximums
| Plan Information | County Health Plan EPO | County Health Plan PPO |
|---|---|---|
| Health Plan Availability | Nationwide | Nationwide |
| Select a Primary Care Physician (PCP) | Does not require you to select a PCP | Does not require you to select a PCP |
| Seeing a Specialist | Allows you access to many types of services without receiving a referral or advance approval | Allows you access to many types of services without receiving a referral or advance approval |
| Dependent Children Eligibility | Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
| Plan Year (June 1 to May 31) Medical Deductible | Individual: $500 Family: $1,500 |
Individual: $300 Family: $900 |
| Plan Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance) | Medical/Prescription Drug Individual: $5,500/$1,100 Family: $11,500/$1,700 |
Medical/Prescription Drug Individual: $2,300/$1,100 Family: $4,900/$1,700 |
Office Visits and Professional Services
| Plan Information | County Health Plan EPO | County Health Plan PPO |
|---|---|---|
| Physician and Specialist | In-Network: $50 copay, no deductible LiveHealth Online: $10 copay Out-of-Network: Not covered |
In-Network: $20 copay, no deductible LiveHealth Online: $10 copay Out-of-Network: 40% coinsurance after deductible |
| Preventive Care Birth to Age 18 | In-Network: No charge, no deductible Out-of-Network: Not covered |
In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible |
| Preventive Care Adult Routine Care | In-Network: No charge, no deductible Out-of-Network: Not covered |
In-Network: No charge, no deductible Out-of-Network: Not covered |
| Preventive Care Adult Routine OB/GYN | In-Network: No charge, no deductible Out-of-Network: Not covered |
In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible |
| Diagnostic Imaging, Lab and X-ray | In-Network: 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible |
| Physical Therapy (medical necessary treatment only) | In-Network: 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible |
| Chiropractic and Acupucture | In-Network: 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible |
| Mental Health and Substance Abuse Disorder (Outpatient) | In-Network:
|
In-Network:
|
| Family Planning Counseling and Consultation | In-Network: $50 copay, no deductible Out-of-Network: Not covered |
In-Network: $20 copay, no deductible Out-of-Network: 40% coinsurance after deductible |
| Routine Eye Exams with Plan Optometrist | In-Network: No charge, no deductible Out-of-Network: Not covered |
In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible |
| Hearing Exam | In-Network: No charge, no deductible Out-of-Network: Not covered |
In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible |
| Allergy Injections (serum included) | In-Network: $50 copay, no deductible, per visit Out-of-Network: Not covered |
In-Network: $20 copay, no deductible, per visit Out-of-Network: 40% coinsurance after deductible |
| Infertility Services | Evaluation (diagnosis) and surgical repair only In-Network: $50 copay, no deductible Out-of-Network: Not covered |
Evaluation (diagnosis) and surgical repair only In-Network: $20 copay, no deductible Out-of-Network:40% coinsurance, after deductible |
Surgical and Hospital Services
| Plan Information | County Health Plan EPO | County Health Plan PPO |
|---|---|---|
| Hospital and Physician/Surgeon Services | In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible |
| Outpatient Surgery | In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible |
| Maternity | In-Network: $250 copay plus 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible |
| Emergency Room | In-Network: $150 copay plus 20% coinsurance after deductible if emergency; otherwise not covered Out-of-Network: $150 copay plus 20% coinsurance after deductible if emergency; otherwise not covered (copays waived if admitted) |
In-Network: $100 copay plus 10% coinsurance after deductible if emergency Out-of-Network: $100 copay plus 10% coinsurance after deductible; If an emergency (copays waived if admitted) |
| Ambulance | In-Network: 20% coinsurance after deductible Out-of-Network: 20% coinsurance after deductible if emergency; otherwise not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 10% coinsurance after deductible if emergency otherwise not covered |
| Mental Health and Substance Abuse Disorder (Inpatient) | In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible |
| Skilled Nursing Facility | In-Network: Not covered Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Up to 100 days per plan year Out-of-Network: 40% coinsurance after deductible Up to 100 days per plan year |
| Home Health | In-Network: Not covered Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Up to 100 visits per plan year Out-of-Network: 40% coinsurance after deductible Up to 100 visits per plan year |
| Urgent Care | In-Network: $50 copay, no deductible Out-of-Network: Not covered |
In-Network: $20 copay, no deductible Out-of-Network: 40% coinsurance, after deductible |
| Hearing Aids | One per ear every 36 months | One per ear every 36 months |
| Durable Medical Equipment | In-Network: 20% coinsurance after deductible Out-of-Network: Not covered |
In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible |
Prescription Drugs
| Plan Information | County Health Plan EPO | County Health Plan PPO |
|---|---|---|
| Generic or Tier 1 | $10 copay Up to 34 day supply |
$5 copay Up to 34 day supply |
| Formulary Brand or Tier 2 | $35 copay Up to 34 day supply |
$20 copay Up to 34 day supply |
| Non-Formulary Brand or Tier 3 | $70 copay Up to 34 day supply |
$40 copay Up to 34 day supply |
| Mail Order Benefit Generic or Tier 1 | $20 copay Up to 90 day supply |
$10 copay Up to 90 day supply |
| Mail Order Benefit Formulary Brand or Tier 2 | $70 copay Up to 90 day supply |
$40 copay Up to 90 day supply |
| Mail Order Benefit Non-Formulary Brand or Tier 3 | $140 copay Up to 90 day supply |
$80 copay Up to 90 day supply |
| Mandatory Mail Order | Yes, through CVS Pharmacy Benefit | Yes, through CVS Pharmacy Benefit |
| Mandatory Generic Program | Yes | Yes |
Traditional HMO
Deductible and Out of Pocket Maximums
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Health Plan Availability | Based on residential zip code. Must live or work in the service area within California | Based on residential zip code. Must live or work in the service area within Northern California | Based on residential zip code. Each person enrolled must live or work in the service area within Northern California |
| Select A Primary Care Physician (PCP) | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs |
| Seeing a Specialist | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests |
| Dependent Children Eligibility | Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
| Calendar Year Deductible | None | None | None |
| Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance) | Individual: $1,500 Any One Member in a family of two or more: $1,500 Family of two or more: $3,000 |
Individual: $1,500 Any One Member in a family of two or more: $1,500 Family of two or more: $3,000 |
Individual: $1,500 Any One Member in a family of two or more: $1,500 Family of two or more: $3,000 |
Office Visits and Professional Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Physician and Specialist Office Visits | $10 copay | $10 copay Telehealth: $5 copay |
$10 copay |
| Preventive Care Birth to Age 18 | No charge | No charge | No charge |
| Preventive Care Adult Routine Care | No charge | No charge | No charge |
| Preventive Care Adult Routine OB/GYN | No charge | No charge | No charge |
| Diagnostic Imaging, Lab and X-ray | No charge | No charge | No charge |
| Physical Therapy (medical necessary treatment only) | $10 copay | $10 copay | $10 copay |
| Chiropractic and Acupuncture | Discounted rates through Kaiser Choose Healthy | Chiropractic: $10 copay Up to 20 visits per year (Chiropractic services do not apply to out-of-pocket maximum) Acupuncture: PCP referral $10 copay LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain. |
Chiropractic: $15 copay Up to 20 visits per year - Copays do not contribute to out-of-pocket maximum Acupuncture: $15 copay Up to 20 visits per year |
| Mental Health and Substance Abuse Disorder (Outpatient) | Individual: $10 copay Group: $5 copay |
www.carelonbh.com/sutterhealthplan Individual: $10 copay Telehealth: $5 copay Group: $5 copay |
www.liveandworkwell.com $10 copay per office or virtual visit Outpatient services: No copay |
| Family Planning Counseling and Consultation |
No charge | No charge | No charge |
| Routine Eye Exams with Plan Optometrist | No charge | No charge for annual refractive eye exam | No charge |
| Hearing Exam | No charge | No charge | No charge |
| Allergy Injections (serum included) | $3 copay | $10 copay with a PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge) | $3 copay |
| Infertility Services | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) |
Surgical and Hospital Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Hospitalization and Physician/Surgeon Services | Facility Fee: No charge Physician/Surgeon Fee: No charge |
Facility Fee: No charge Physician/Surgeon Fee: No charge |
Facility Fee: No charge Physician/Surgeon Fee: No charge |
| Outpatient Surgery | $10 copay | $10 copay | $10 copay |
| Maternity | No charge | No charge | No charge |
| Emergency Room | $50 copay (waived if admitted) | $50 copay (waived if admitted) | $50 copay (waived if admitted) |
| Ambulance | $50 per trip | $50 per trip | $50 per trip |
| Mental Health and Substance Abuse Disorder (Inpatient) | No charge |
www.carelonbh.com/sutterhealthplan No charge |
No charge |
| Skilled Nursing Facility | No charge Up to 100 days per benefit period |
No charge Up to 100 days per benefit period |
No charge Up to 100 days per benefit period |
| Home Health | No charge Up to 100 visits per year |
No charge Up to 100 visits per year |
No charge Up to 100 visits per year |
| Urgent Care | $10 copay | $10 copay | $10 copay |
| Hearing Aids |
Not covered
|
Not covered
|
Not covered
|
| Durable Medical Equipment | 20% coinsurance in accordance with formulary | No charge | 20% coinsurance |
Prescription Drugs
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Generic or Tier 1 | $5 copay Up to 100 day supply |
$5 copay Up to 30 day supply |
$5 copay Up to 30 day supply |
| Formulary Brand or Tier 2 | $10 copay Up to 100 day supply |
$10 copay Up to 30 day supply |
$10 copay Up to 30 day supply |
| Non-Formulary Brand or Tier 3 | $10 copay Up to 100 day supply |
Tier 3: $20 copay Up to 30 day supply Tier 4 (Specialty Drug): $20 copay Up to a 30 day supply only |
$20 copay Up to 30 day supply |
| Mail Order Benefit Generic or Tier 1 | $5 copay Up to 100 day supply |
$10 copay Up to 100 day supply |
$5 copay Up to 90 day supply |
| Mail Order Benefit Formulary Brand or Tier 2 | $10 copay Up to 100 day supply |
$20 copay Up to 100 day supply |
$10 copay Up to 90 day supply |
| Mail Order Benefit Non-Formulary Brand or Tier 3 | $10 copay Up to 100 day supply |
$40 copay Up to 100 day supply |
$20 copay Up to 90 day supply |
| Mandatory Mail Order | No | No | No |
| Mandatory Generic Program | N/A | Dispense as written program | Yes |
Hospital Services DHMO
Deductible and Out of Pocket Maximums
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Health Plan Availability | Based on residential zip code. Must live or work in the service area within California | Based on residential zip code. Must live or work in the service area within Northern California | Based on residential zip code. Each person enrolled must live or work in the service area within Northern California |
| Select A Primary Care Physician (PCP) | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs |
| Seeing a Specialist | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests |
| Dependent Children Eligibility | Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
| Calendar Year Deductible | Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000 |
Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000 |
Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000 |
| Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance) | Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000 |
Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000 |
Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000 |
Office Visits and Professional Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Physician and Specialist Office Visits | $20 copay, no deductible | $20 copay, no deductible Telehealth: $10 copay, no deductible |
$20 copay, no deductible |
| Preventive Care Birth to Age 18 | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Preventive Care Adult Routine Care | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Preventive Care Adult Routine OB/GYN | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Diagnostic Imaging, Lab and X-ray | Diagnostic Lab: $10 copay per encounter, no deductible Diagnostic X-ray: $10 copay per encounter, no deductible CT/PET Scans & MRI: $50 per procedure, no deductible |
Diagnostic Lab: $20 copay per encounter, no deductible Diagnostic X-ray: $10 copay per encounter, no deductible CT/PET Scans & MRI: $50 per procedure, no deductible |
Diagnostic Lab: No charge, no deductible Diagnostic X-ray: No charge, no deductible |
|
Physical Therapy (Medical necessary treatment only) |
$20 copay , no deductible | $20 copay , no deductible | $20 copay , no deductible |
| Chiropractic and Acupuncture | Discounted rates through Kaiser Choose Healthy | Chiropractic: $20 copay Up to 20 visits per year (Chiropractic services do not apply to out-of-pocket maximum) Acupuncture: PCP referral $20 copay LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain. |
Chiropractic: $15 copay
Up to 20 visits per year - Copays do not contribute to out-of-pocket maximum Acupuncture: $15 copay, no deductible. Up to 20 visits per year |
| Mental Health and Substance Abuse Disorder (Outpatient) | MH/SUD Individual: $20 copay, no deductible MH group: $10 copay, no deductible SUD group: $5 copay, no deductible |
www.carelonbh.com/sutterhealthplan MH/SUD Individual: $20 copay, no deductible MH/SUD group: $10 copay, no deductible |
www.liveandworkwell.com $20 copay, no deductible, per office or virtual visit Outpatient services: No copay, no deductible |
| Family Planning Counseling and Consultation | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Routine Eye Exams with Plan Optometrist | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Hearing Exam | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Allergy Injections (serum included) | No charge, no deductible | $20 copay, no deductible with a PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge, no deductible) | No charge, no deductible |
| Infertility Services | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) |
Surgical and Hospital Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Hospitalization and Physician/Surgeon Services | 20% coinsurance after deductible | 20% coinsurance after deductible | 20% coinsurance after deductible |
| Outpatient Surgery | 20% coinsurance after deductible | 20% coinsurance after deductible | $20 copay per visit, no deductible, performed in office setting 20% coinsurance after deductible, performed in facility |
| Maternity | 20% coinsurance after deductible | 20% coinsurance after deductible | 20% coinsurance after deductible |
| Emergency Room | 20% coinsurance after deductible | 20% coinsurance after deductible | 20% coinsurance after deductible |
| Ambulance | $150 per trip, no deductible | No charge after deductible | $150 per trip, no deductible |
| Mental Health Substance Abuse Disorder (Inpatient) | 20% coinsurance after deductible |
www.carelonbh.com/sutterhealthplan 20% coinsurance after deductible |
20% coinsurance after deductible |
| Skilled Nursing Facility | 20% coinsurance, no deductible Up to 100 days per benefit period |
20% coinsurance after deductible Up to 100 days per benefit period |
20% coinsurance, no deductible Up to 100 days per benefit period |
| Home Health | No charge, no deductible Up to 100 visits per year |
No charge, no deductible Up to 100 visits per calendar year |
No charge, no deductible Up to 100 visits per year |
| Urgent Care | $20 copay, no deductible | $20 copay, no deductible | $20 copay, no deductible |
| Hearing Aids | Not covered | Not covered | Not covered |
| Durable Medical Equipment | 20% coinsurance in accordance with formulary, no deductible | 20% coinsurance after deductible | 20% coinsurance, no deductible |
Prescription Drugs
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Generic or Tier 1 | $10 copay, no deductible Up to 30 day supply |
$10 copay, no deductible Up to 30 day supply |
$10 copay, no deductible Up to 30 day supply |
| Formulary Brand or Tier 2 | $30 copay, no deductible Up to 30 day supply |
$30 copay, no deductible Up to 30 day supply |
$30 copay, no deductible Up to 30 day supply |
| Non-Formulary Brand or Tier 3 | $30 copay, no deductible Up to 30 day supply (Must be deemed medically necessary under the treatment of the Kaiser physician) |
Tier 3: $60 copay, no deductible Up to 30 day supply Tier 4 (Specialty Drug): 20% coinsurance ($100 per prescription maximum), no deductible Up to 30 day supply |
$50 copay, no deductible Up to 30 day supply |
| Mail Order Benefit Generic or Tier 1 | $20 copay, no deductible Up to 100 day supply |
$20 copay, no deductible Up to 100 day supply |
$20 copay, no deductible Up to 90 day supply |
| Mail Order Benefit Formulary Brand or Tier 2 | $60 copay, no deductible Up to 100 day supply |
$60 copay, no deductible Up to 100 day supply |
$60 copay, no deductible Up to 90 day supply |
| Mail Order Benefit Non-Formulary Brand or Tier 3 | $60 copay, no deductible Up to 100 day supply |
$120 copay, no deductible Up to 100 day supply |
$100 copay, no deductible Up to 90 day supply |
| Mandatory Mail Order | No | No | No |
| Mandatory Generic Program | N/A | Dispense as written program | Yes |
Deductible First HDHP
Deductible and Out of Pocket Maximums
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Health Plan Availability | Based on residential zip code. Must live or work in the service area within California | Based on residential zip code. Must live or work in the service area within Northern California | Based on residential zip code. Each person enrolled must live or work in the service area within Northern California |
| Select A Primary Care Physician (PCP) | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs | Requires you to select a PCP who will work with you to manage your health care needs |
| Seeing a Specialist | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests |
| Dependent Children Eligibility | Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
Dependent child under age 26 Disabled: No age limit |
| Calendar Year Deductible | Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200 |
Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200 |
Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200 |
| Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays Coinsurance) | Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400 |
Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400 |
Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400 |
Office Visits and Professional Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Physician and Specialist office visits | $20 copay after deductible | $20 copay after deductible Telehealth: $10 copay after deductible |
$20 copay after deductible |
| Preventive Care Birth to Age 18 | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Preventive Care Adult Routine Care | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Preventive Care Adult Routine OB/GYN | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Diagnostic Imaging, Lab and X-ray | Diagnostic Lab: $10 copay after deductible, per encounter Diagnostic X-ray: $10 copay after deductible, per encounter CT/PET Scans & MRI: $50 per procedure after deductible |
Diagnostic Lab: $20 copay after deductible Diagnostic X-ray: $10 copay after deductible, per procedure CT/PET Scans & MRI: $50 copay after deductible, per procedure |
No charge after deductible |
| Physical Therapy (medical necessary treatment only) | $20 copay after deductible | $20 copay after deductible | $20 copay after deductible |
| Chiropractic and Acupuncture | Discounted rates through Kaiser Choose Healthy | Chiropractic: Not covered Acupuncture: PCP referral $20 copay after deductible LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain |
No charge after deductible Up to 20 visits per year |
| Mental Health and Substance Abuse Disorder (Outpatient) | MH/SUD individual: $20 copay after deductible MH group: $10 copay after deductible SUD group: $5 copay after deductible |
www.carelonbh.com/sutterhealthplan MH/SUD individual: $20 copay after deductible, per visit Virtual Visit: $10 copay after deductible MH/SUD group: $10 copay after deductible, per visit |
www.liveandworkwell.com $20 copay after deductible, per office or virtual visit Outpatient services: No copay, after deductible |
| Family Planning Counseling and Consultation | No charge, no deductible | No charge, no deductible | $20 copay after deductible |
| Routine Eye Exams with Plan Optometrist | $20 copay, no deductible | No charge, no deductible | No charge, no deductible |
| Hearing Exam | No charge, no deductible | No charge, no deductible | No charge, no deductible |
| Allergy Injections (serum included) | $5 copay after deductible | $20 copay after deductible with PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge, after deductible) | $5 copay after deductible |
| Infertility Services | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) | covered at standard cost share, based on type of service (e.g., office visit, outpatient lab, etc.) |
Surgical and Hospital Services
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Hospitalization and Physician/Surgeon Services | $250 copay after deductible, per admission Inpatient Physician Services: No charge after deductible |
Hospitalization Facility Fee: $250 copay after deductible, per day Up to 5 days per admission Inpatient Physician Services: No charge after deductible |
$250 copay after deductible, per admission Inpatient Physician Services: No charge after deductible |
| Outpatient Surgery | $150 copay after deductible, per procedure | $20 copay after deductible, per visit | $150 copay after deductible, per procedure |
| Maternity | $250 copay after deductible, per admission | Hospitalization Facility Fee: $250 copay per day after deductible Up to 5 days per admission Inpatient Physician Services: No charge after deductible |
$250 copay after deductible, per admission |
| Emergency Room | $100 copay after deductible | $100 copay after deductible | $100 copay after deductible |
| Ambulance | $100 copay after deductible, per trip | $100 copay per trip, after deductible | $100 copay after deductible, per trip |
| Mental Health & Substance Abuse Disorder (Inpatient) | $250 copay after deductible, per admission |
www.carelonbh.com/sutterhealthplan MH/SUD Inpatient Facility: $250 copay per day after deductible |
$250 copay after deductible, per admission |
| Skilled Nursing Facility | $250 copay after deductible, per admission Up to 100 days per benefit period |
$100 copay after deductible, per day Up to 5 days per admission Up to 100 days per benefit period |
$250 copay after deductible, per admission Up to 100 days per benefit period |
| Home Health | No charge after deductible Up to 100 visits per year |
No charge after deductible Up to 100 visits per year |
No charge after deductible Up to 100 visits per year |
| Urgent Care | $20 copay after deductible | $20 copay after deductible | $20 copay after deductible |
| Hearing Aids | Not covered | Not covered | Not covered |
| Durable Medical Equipment | 20% coinsurance after deductible in accordance with formulary | 20% coinsurance after deductible | 20% coinsurance after deductible |
Prescription Drugs
| Plan Information | Kaiser Permanente | Sutter Health Plan | Western Health Advantage |
|---|---|---|---|
| Generic or Tier 1 | $10 copay after deductible Up to 30 day supply |
$10 copay after deductible Up to 30 day supply |
$10 copay after deductible Up to 30 day supply |
| Formulary Brand or Tier 2 | $30 copay after deductible Up to 30 day supply |
$30 copay after deductible Up to 30 day supply |
$30 copay after deductible Up to 30 day supply |
| Non-Formulary Brand or Tier 3 | $30 copay Up to 30 day supply after deductible (Must be deemed medically necessary under the treatment of the Kaiser physician) |
Tier 3:$60 copay after deductible Up to 30 day supply Tier 4 (Specialty Drug):20% coinsurance ($100 per prescription maximum) after deductible Up to 30 day supply |
$50 copay after deductible Up to 30 day supply |
| Mail Order Benefit Generic or Tier 1 | $20 copay after deductible Up to 100 day supply |
$20 copay after deductible Up to 100 day supply |
$20 copay after deductible Up to 90 day supply |
| Mail Order Benefit Formulary Brand or Tier 2 | $60 copay after deductible Up to 100 day supply |
$60 copay after deductible Up to 100 day supply |
$60 copay after deductible Up to 90 day supply |
| Mail Order Benefit Non-Formulary Brand or Tier 3 | $60 copay after deductible Up to 100 day supply |
$120 copay after deductible Up to 100 day supply |
$100 copay after deductible Up to 90 day supply |
| Mandatory Mail Order | No | No | No |
| Mandatory Generic Program | N/A | Dispense as written program | Yes |
Medicare Plans
Deductible and Out of Pocket Maximums
| Plan Information | Kaiser Permanente Senior Advantage | Anthem Medicare Preferred (PPO) and Blue Cross MedicareRx (PDP) |
|---|---|---|
| Health Plan Availability | Based on residential zip code. Must live in service area within California, Hawaii, and the Northwest (Oregon/ Washington); rates vary by state | Nationwide |
| Select a Primary Care Physician (PCP) | Requires you to select a PCP who will work with you to manage your health care needs | Does not require you to select a PCP |
| Seeing a Specialist | Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests | You can see any doctor, specialist, or other care provider in or out of the plan's network who accepts both Medicare and the Anthem plan, without a referral |
| Dependent Children Eligibility | Dependent child under age 26 Disabled: No age limit |
Medicare eligible only |
| Calendar Year Deductible | None | None |
| Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance) |
Medical: $1,000 Prescription Drug: $2,100 |
Medical: $0 Prescription Drug: $2,100 |
Office Visits and Professional Services
| Plan Information | Kaiser Permanente Senior Advantage | Anthem Medicare Preferred (PPO) and Blue Cross MedicareRx (PDP) |
|---|---|---|
| Physician and Specialist Office Visits | $10 copay | No charge |
| Preventive Care Birth to Age 18 | No charge | N/A |
| Preventive Care Adult Routine Care | No charge | No charge |
| Preventive Care Adult Routine OB/GYN | No charge | No charge |
| Diagnostic Imaging, Lab and X-ray | No charge | No charge |
| Physical Therapy (medical necessary treatment only) | $10 copay | No charge |
| Chiropractic and Acupuncture | Discounted rates through Kaiser On Pass Affinity (Non-Medical) One Pass (Medicare) |
No charge |
| Mental Health and Substance Abuse Disorder (Outpatient) | Individual: $10 copay Group: $5 copay |
No charge |
Surgical and Hospital Services
| Plan Information | Kaiser Permanente Senior Advantage | Anthem Medicare Preferred (PPO) and Blue Cross MedicareRx (PDP) |
|---|---|---|
| Hospitalization and Physician/Surgeon Services | Facility Fee: No charge Physician/Surgeon Fee: No charge |
No charge |
| Outpatient Surgery | $10 copay | No charge |
| Maternity | No charge | No charge |
| Emergency Room | $50 copay (waived if admitted) | $100 copay |
| Ambulance | $50 per trip | No charge |
| Mental Health and Substance Abuse Disorder (Inpatient) | No charge | No charge |
| Skilled Nursing Facility | No charge Up to 100 days per benefit period |
No charge |
| Home Health | No charge | No charge |
| Hearing Aids | Not covered | $500 per ear with a maximum benefit of $1000 per ear every three calendar years through TruHearing |
Prescription Drugs
| Plan Information | Kaiser Permanente Senior Advantage | Anthem Medicare Preferred (PPO) and Blue Cross MedicareRx (PDP) |
|---|---|---|
| Generic or Tier 1 | $5 copay Up to 100 day supply |
$0 copay for select generics $5 copay for generics Up to 30 day supply |
| Formulary Brand or Tier 2 | $10 copay Up to 100 day supply |
$10 copay Up to 30 day supply |
| Non-Formulary Brand or Tier 3 | $10 copay Up to 100 day supply |
(Includes Speciality Drugs) $10 copay Up to 30 day supply |
| Mail Order Benefit Generic or Tier 1 | $5 copay Up to 100 day supply |
$0 copay for select generics $10 copay for generics Up to 90 day supply |
| Mail Order Benefit Formulary Brand or Tier 2 | $10 copay Up to 100 day supply |
$20 copay Up to 90 day supply |
| Mail Order Benefit Non-Formulary Brand or Tier 3 | $10 copay Up to 100 day supply |
(Includes Speciality Drugs up to 30 day supply) $20 copay Up to 90 day supply |
| Mandatory Mail Order | No | No |
| Mandatory Generic Program | No | No |
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