Medical Plan Comparison

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	Blue Shield CDHP		Blue Shield PPO		Kaiser HMO	Kaiser CDHP
	In-Network	Out-of-Network	In-Network	Out-of-Network	Details	Details
Annual Deductible
Individual	$1,500 (combined with in-network)	$1,500 (combined with out-of-network)	$500 per individual	$1,000 per individual	None	$1,500 (combined with in-network)
Family	$2,800 per individual, up to $3,000 per family (combined with in-network)	$2,800 per individual, up to $3,000 family (combined with out-of-network)	$500 per individual, up to $1,000 per family	$1,000 per individual, up to $2,000 per family	None	$2,800 per individual, up to $3,000 per family (combined with in-network)
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	You pay 10%	You pay 30%	None	None
Annual Out-of-Pocket Maximum
Individual	$3,000	$6,000	$2,000 per individual (combined with out-ofnetwork)	$4,000 per individual	$1,500	$3,000
Family	$3,000 individual, up to $6,000 per family	$6,000 per individual, up to $12,000 per family	$2,000 per individual, up to $4,000 per family (combined with out-of-network)	$4,000 per individual, up to $8,000 per family	$1,500 per individual, up to $3,000 per family	$3,000 individual, up to $6,000 per family
Deductible Included in Out-of-Pocket Maximum	Yes	Yes	N/A	Yes	N/A	N/A
Lifetime Maximum	Unlimited	Unlimited	Unlimited	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A	Negotiated Fees	N/A	N/A
Primary Care Physician Election Required?	No	No	No	No	Yes
Outpatient Services
Office Visit	10% after deductible	30% after deductible	$20 copay	30% after deductible	$25 copay	10% after deductible
Specialist Offce Visit	10% after deductible	30% after deductible	$40 copay	30% after deductible	$25 copay	10% after deductible
Maternity Offce Visit (PreNatal Care)	10% after deductible	30% after deductible	10% after deductible	30% after deductible	No charge	10% after deductible
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	10% after deductible	30% after deductible (coverage limited to $350 per day)	$25 per procedure	10% after deductible
Diagnostic Laboratory & X-Ray	10% after deductible; Hospital Setting: Lab/Xray – $25 + 10% after deductible & Complex Imaging – $100 + 10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	X-ray and Lad: $20 copay after deductible; Complex Imaging: 10% after deductible	30% after deductible (coverage limited to $350 per day at hospital)	No charge	10% after deductible
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered	No charge	No charge
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered	No charge	No charge
Bridges	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered	No charge	No charge
Inpatient Hospitalization	$100 per admission + 10% after deductible	30% after deductible (coverage limited to $600 per day)	10% after deductible	30% after deductible (coverage limited to $600 per day)	$250 per admission	10% after deductible
Emergency Room	$100 per admission + 10% after deductible	$100 per admission + 10% after deductible (waived if admitted)	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit, waived if admitted	10% after deductible
Prescription Drugs
Deductible	Included in plan deductible	Included in plan deductible	N/A	N/A	N/A
Retail
Generic	$10 copay after deductible	$10 copay after deductible + 25%	$10 copay	$10 copay + 25%	$10 copay	$10 copay after deductible
Brand (Formulary)	$25 copay after deductible	$25 copay after deductible + 25%	$30 copay	$30 copay + 25%	$30 copay	$30 copay after deductible
Brand (Non-Formulary)	$40 copay after deductible	$40 copay after deductible + 25%	$50 copay	$50 copay + 25%	$30 copay (prior authorization required)	20% coinsurance (not to exceed $200) after deductible
Number of Days Supply	30 days	30 days	30 days	30 days	30 days	30 days
Mail-Order
Generic	$20 copay after deductible	Not covered	$20 copay	Not covered	$20 copay	$20 copay
Brand (Formulary)	$50 copay after deductible	Not covered	$60 copay	Not covered	$60 copay	$60 copay
Brand (Non-Formulary)	$80 copay after deductible	Not covered	$100 copay	Not covered	$60 copay (prior authorization required)	$60 copay (prior authorization required)
Number of Days Supply	90 days	N/A	90 days	N/A	100 days	100 days
Outpatient Rehabilitative Therapy Services
Physical	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Occupational	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Speech	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible; No charge for breast pump	30% after deductible; Breast pump not covered	10% after deductible	30% after deductible	You pay 20% coinsurance per item
Prosthetic Devices	10% after deductible	30% after deductible	10% after deductible	30% after deductible	No charge
Chiropractic	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with acupuncture)	$15 per visit (up to 20 visits per year combined with acupuncture) after plan deductible
Acupuncture	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with chiropractic)
Infertility	50% coinsurance	Not covered	50% coinsurance	Not covered	You pay 50% coinsurance (coverage limited to diagnosis & treatment; articial insemination)
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered	No charge (coverage limited to 100 visits per calendar year)
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year, combined with outof-network; preauthorization required)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)	10% after deductible (coverage limited to 100 days per member per year combined with outof-network)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)	No charge (coverage limited to 100 days per benefit period)

	Blue Shield PPO		Kaiser HMO
	In-Network	Out-of-Network	Details
Annual Deductible
Individual	$500 per individual	$1,000 per individual	None
Family	$500 per individual, up to $1,000 per family	$1,000 per individual, up to $2,000 per family	None
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	None
Annual Out-of-Pocket Maximum
Individual	$2,000 per individual (combined with out-of-network)	$4,000 per individual	$1,500
Family	$2,000 per individual, up to $4,000 per family (combined with out-of-network)	$4,000 per individual, up to $8,000 per family	$1,500 per individual, up to $3,000 per family
Deductible Included in Out-of-Pocket Maximum	N/A	Yes	N/A
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A
Primary Care Physician Election Required?	No	No	Yes
Outpatient Services
Office Visit	$20 copay	30% after deductible	$25 copay
Specialist Office Visit	$40 copay	30% after deductible	$25 copay
Maternity Office Visit (PreNatal Care)	10% after deductible	30% after deductible	No charge
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	$25 per procedure
Diagnostic Laboratory & X-Ray	X-ray and Lad: $20 copay after deductible; Complex Imaging: 10% after deductible	30% after deductible (coverage limited to $350 per day at hospital)	No charge
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Bridges	No charge (deductible waived)	Not covered	No charge
Inpatient Hospitalization	10% after deductible	30% after deductible (coverage limited to $600 per day)	$250 per admission
Emergency Room	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit, waived if admitted
Prescription Drugs
Deductible	N/A	N/A	N/A
Retail
Generic	$10 copay	$10 copay + 25%	$10 copay
Brand (Formulary)	$30 copay	$30 copay + 25%	$30 copay
Brand (Non-Formulary)	$50 copay	$50 copay + 25%	$30 copay (prior authorization required)
Number of Days Supply	30 days	30 days	30 days
Mail-Order
Generic	$20 copay	Not covered	$20 copay
Brand (Formulary)	$60 copay	Not covered	$60 copay
Brand (Non-Formulary)	$100 copay	Not covered	$60 copay (prior authorization required)
Number of Days Supply	90 days	N/A	100 days
Outpatient Rehabilitative Therapy Services
Physical	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Occupational	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Speech	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible	30% after deductible	You pay 20% coinsurance per item
Prosthetic Devices	10% after deductible	30% after deductible	No charge
Chiropractic	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with acupuncture)
Acupuncture	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with chiropractic)
Infertility	50% coinsurance	Not covered	You pay 50% coinsurance (coverage limited to diagnosis & treatment; artificial insemination)
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered	No charge (coverage limited to 100 visits per calendar year)
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year combined with out-of-network)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)	No charge (coverage limited to 100 days per benet period)

	Blue Shield CDHP		Kaiser HMO
	In-Network	Out-of-Network	Details
Annual Deductible
Individual	$1,500 (combined with in-network)	$1,500 (combined with out-of-network)	None
Family	$2,800 per individual, up to $3,000 per family (combined with in-network)	$2,800 per individual, up to $3,000 family (combined with out-of-network)	None
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	None
Annual Out-of-Pocket Maximum
Individual	$3,000	$6,000	$1,500
Family	$3,000 individual, up to $6,000 per family	$6,000 per individual, up to $12,000 per family	$1,500 per individual, up to $3,000 per family
Deductible Included in Out-of-Pocket Maximum	Yes	Yes	N/A
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A
Primary Care Physician Election Required?	No	No	Yes
Outpatient Services
Office Visit	10% after deductible	30% after deductible	$25 copay
Specialist Office Visit	10% after deductible	30% after deductible	$25 copay
Maternity Office Visit (PreNatal Care)	10% after deductible	30% after deductible	No charge
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	$25 per procedure
Diagnostic Laboratory & X-Ray	10% after deductible; Hospital Setting: Lab/Xray – $25 + 10% after deductible & Complex Imaging – $100 + 10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	No charge
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Bridges	No charge (deductible waived)	Not covered	No charge
Inpatient Hospitalization	$100 per admission + 10% after deductible	30% after deductible (coverage limited to $600 per day)	$250 per admission
Emergency Room	$100 per admission + 10% after deductible	$100 per admission + 10% after deductible (waived if admitted)	$100 per visit, waived if admitted
Prescription Drugs
Deductible	Included in plan deductible	Included in plan deductible	N/A
Retail
Generic	$10 copay after deductible	$10 copay after deductible + 25%	$10 copay
Brand (Formulary)	$25 copay after deductible	$25 copay after deductible + 25%	$30 copay
Brand (Non-Formulary)	$40 copay after deductible	$40 copay after deductible + 25%	$30 copay (prior authorization required)
Number of Days Supply	30 days	30 days	30 days
Mail-Order
Generic	$20 copay after deductible	Not covered	$20 copay
Brand (Formulary)	$50 copay after deductible	Not covered	$60 copay
Brand (Non-Formulary)	$80 copay after deductible	Not covered	$60 copay (prior authorization required)
Number of Days Supply	90 days	N/A	100 days
Outpatient Rehabilitative Therapy Services
Physical	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Occupational	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Speech	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$25 per visit
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible; No charge for breast pump	30% after deductible; Breast pump not covered	You pay 20% coinsurance per item
Prosthetic Devices	10% after deductible	30% after deductible	No charge
Chiropractic	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with acupuncture)
Acupuncture	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$15 per visit (coverage limited to 20 visits per calendar year combined with chiropractic)
Infertility	50% coinsurance	Not covered	You pay 50% coinsurance (coverage limited to diagnosis & treatment; articial insemination)
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered	No charge (coverage limited to 100 visits per calendar year)
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year, combined with outof-network; preauthorization required)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)	No charge (coverage limited to 100 days per benet period)

	Blue Shield CDHP		Blue Shield PPO
	In-Network	Out-of-Network	In-Network	Out-of-Network
Annual Deductible
Individual	$1,500 (combined with in-network)	$1,500 (combined with out-of-network)	$500 per individual	$1,000 per individual
Family	$2,800 per individual, up to $3,000 per family (combined with in-network)	$2,800 per individual, up to $3,000 family (combined with out-of-network)	$500 per individual, up to $1,000 per family	$1,000 per individual, up to $2,000 per family
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	You pay 10%	You pay 30%
Annual Out-of-Pocket Maximum
Individual	$3,000	$6,000	$2,000 per individual (combined with out-ofnetwork)	$4,000 per individual
Family	$3,000 individual, up to $6,000 per family	$6,000 per individual, up to $12,000 per family	$2,000 per individual, up to $4,000 per family (combined with out-ofnetwork)	$4,000 per individual, up to $8,000 per family
Deductible Included in Out-of-Pocket Maximum	Yes	Yes	N/A	Yes
Lifetime Maximum	Unlimited	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A	Negotiated Fees
Primary Care Physician Election Required?	No	No	No	No
Outpatient Services
Office Visit	10% after deductible	30% after deductible	$20 copay	30% after deductible
Specialist Office Visit	10% after deductible	30% after deductible	$40 copay	30% after deductible
Maternity Office Visit (PreNatal Care)	10% after deductible	30% after deductible	10% after deductible	30% after deductible
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	10% after deductible	30% after deductible (coverage limited to $350 per day)
Diagnostic Laboratory & X-Ray	10% after deductible; Hospital Setting: Lab/Xray – $25 + 10% after deductible & Complex Imaging – $100 + 10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	X-ray and Lad: $20 copay after deductible; Complex Imaging: 10% after deductible	30% after deductible (coverage limited to $350 per day at hospital)
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered
Bridges	No charge (deductible waived)	Not covered	No charge (deductible waived)	Not covered
Inpatient Hospitalization	$100 per admission + 10% after deductible	30% after deductible (coverage limited to $600 per day)	10% after deductible	30% after deductible (coverage limited to $600 per day)
Emergency Room	$100 per admission + 10% after deductible	$100 per admission + 10% after deductible (waived if admitted)	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit (copay waived if admitted; deductible waived)
Prescription Drugs
Deductible	Included in plan deductible	Included in plan deductible	N/A	N/A
Retail
Generic	$10 copay after deductible	$10 copay after deductible + 25%	$10 copay	$10 copay + 25%
Brand (Formulary)	$25 copay after deductible	$25 copay after deductible + 25%	$30 copay	$30 copay + 25%
Brand (Non-Formulary)	$40 copay after deductible	$40 copay after deductible + 25%	$50 copay	$50 copay + 25%
Number of Days Supply	30 days	30 days	30 days	30 days
Mail-Order
Generic	$20 copay after deductible	Not covered	$20 copay	Not covered
Brand (Formulary)	$50 copay after deductible	Not covered	$60 copay	Not covered
Brand (Non-Formulary)	$80 copay after deductible	Not covered	$100 copay	Not covered
Number of Days Supply	90 days	N/A	90 days	N/A
Outpatient Rehabilitative Therapy Services
Physical	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Occupational	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Speech	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible; No charge for breast pump	30% after deductible; Breast pump not covered	10% after deductible	30% after deductible
Prosthetic Devices	10% after deductible	30% after deductible	10% after deductible	30% after deductible
Chiropractic	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)
Acupuncture	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)
Infertility	50% coinsurance	Not covered	50% coinsurance	Not covered
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year, combined with outof-network; preauthorization required)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and innetwork)	10% after deductible (coverage limited to 100 days per member per year combined with outof-network)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and innetwork)

	Blue Shield PPO		Kaiser CDHP
	In-Network	Out-of-Network	Details
Annual Deductible
Individual	$500 per individual	$1,000 per individual	$1,500 (combined with in-network)
Family	$500 per individual, up to $1,000 per family	$1,000 per individual, up to $2,000 per family	$2,800 per individual, up to $3,000 per family (combined with in-network)
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	None
Annual Out-of-Pocket Maximum
Individual	$2,000 per individual (combined with out-of-network)	$4,000 per individual	$3,000
Family	$2,000 per individual, up to $4,000 per family (combined with out-of-network)	$4,000 per individual, up to $8,000 per family	$3,000 individual, up to $6,000 per family
Deductible Included in Out-of-Pocket Maximum	N/A	Yes	N/A
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A
Primary Care Physician Election Required?	No	No
Outpatient Services
Office Visit	$20 copay	30% after deductible	10% after deductible
Specialist Office Visit	$40 copay	30% after deductible	10% after deductible
Maternity Office Visit (PreNatal Care)	10% after deductible	30% after deductible	10% after deductible
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	10% after deductible
Diagnostic Laboratory & X-Ray	X-ray and Lad: $20 copay after deductible; Complex Imaging: 10% after deductible	30% after deductible (coverage limited to $350 per day at hospital)	10% after deductible
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Bridges	No charge (deductible waived)	Not covered	No charge
Inpatient Hospitalization	10% after deductible	30% after deductible (coverage limited to $600 per day)	10% after deductible
Emergency Room	$100 per visit (copay waived if admitted; deductible waived)	$100 per visit (copay waived if admitted; deductible waived)	10% after deductible
Prescription Drugs
Deductible	N/A	N/A
Retail
Generic	$10 copay	$10 copay + 25%	$10 copay after deductible
Brand (Formulary)	$30 copay	$30 copay + 25%	$30 copay after deductible
Brand (Non-Formulary)	$50 copay	$50 copay + 25%	20% coinsurance (not to exceed $200) after deductible
Number of Days Supply	30 days	30 days	30 days
Mail-Order
Generic	$20 copay	Not covered	$20 copay
Brand (Formulary)	$60 copay	Not covered	$60 copay
Brand (Non-Formulary)	$100 copay	Not covered	$60 copay (prior authorization required)
Number of Days Supply	90 days	N/A	100 days
Outpatient Rehabilitative Therapy Services
Physical	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Occupational	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Speech	$20 copay after deductible	30% after deductible (hospital coverage limited to $350 per day)
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible	30% after deductible
Prosthetic Devices	10% after deductible	30% after deductible
Chiropractic	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)	$15 per visit (up to 20 visits per year combined with acupuncture) after plan deductible
Acupuncture	$25 per visit (coverage limited to 20 visits per calendar year combined with out-of-network)	30% after deductible (coverage limited to 20 visits per calendar year combined with in-network)
Infertility	50% coinsurance	Not covered
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year combined with out-of-network)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)

	Blue Shield CDHP		Kaiser CDHP
	In-Network	Out-of-Network	Details
Annual Deductible
Individual	$1,500 (combined with in-network)	$1,500 (combined with out-of-network)	$1,500 (combined with in-network)
Family	$2,800 per individual, up to $3,000 per family (combined with in-network)	$2,800 per individual, up to $3,000 family (combined with out-of-network)	$2,800 per individual, up to $3,000 per family (combined with in-network)
Plan Accumulation	Calendar Year	Calendar Year	Calendar Year
Coinsurance	You pay 10%	You pay 30%	None
Annual Out-of-Pocket Maximum
Individual	$3,000	$6,000	$3,000
Family	$3,000 individual, up to $6,000 per family	$6,000 per individual, up to $12,000 per family	$3,000 individual, up to $6,000 per family
Deductible Included in Out-of-Pocket Maximum	Yes	Yes	N/A
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	Negotiated Fees	N/A
Primary Care Physician Election Required?	No	No
Outpatient Services
Office Visit	10% after deductible	30% after deductible	10% after deductible
Specialist Office Visit	10% after deductible	30% after deductible	10% after deductible
Maternity Office Visit (PreNatal Care)	10% after deductible	30% after deductible	10% after deductible
Outpatient Surgery	10% after deductible	30% after deductible (coverage limited to $350 per day)	10% after deductible
Diagnostic Laboratory & X-Ray	10% after deductible; Hospital Setting: Lab/Xray – $25 + 10% after deductible & Complex Imaging – $100 + 10% after deductible	30% after deductible (hospital coverage limited to $350 per day)	10% after deductible
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Adult Periodic Exams with Preventive Tests	No charge (deductible waived)	Not covered	No charge
Bridges	No charge (deductible waived)	Not covered	No charge
Inpatient Hospitalization	$100 per admission + 10% after deductible	30% after deductible (coverage limited to $600 per day)	10% after deductible
Emergency Room	$100 per admission + 10% after deductible	$100 per admission + 10% after deductible (waived if admitted)	10% after deductible
Prescription Drugs
Deductible	Included in plan deductible	Included in plan deductible	N/A
Retail
Generic	$10 copay after deductible	$10 copay after deductible + 25%	$10 copay
Brand (Formulary)	$25 copay after deductible	$25 copay after deductible + 25%	$30 copay
Brand (Non-Formulary)	$40 copay after deductible	$40 copay after deductible + 25%	20% coinsurance (not to exceed $200) after deductible
Number of Days Supply	30 days	30 days	30 days
Mail-Order
Generic	$20 copay after deductible	Not covered	$20 copay
Brand (Formulary)	$50 copay after deductible	Not covered	$60 copay
Brand (Non-Formulary)	$80 copay after deductible	Not covered	$60 copay (prior authorization required)
Number of Days Supply	90 days	N/A	100 days
Outpatient Rehabilitative Therapy Services
Physical	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)
Occupational	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)
Speech	10% after deductible	30% after deductible (hospital coverage limited to $350 per day)
Other Services and Supplies
Mental Health/Substance Abuse	Inpatient and outpatient covered under general plan design	Inpatient and outpatient covered under general plan design
Durable Medical Equipment	10% after deductible; No charge for breast pump	30% after deductible; Breast pump not covered
Prosthetic Devices	10% after deductible	30% after deductible
Chiropractic	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)	$15 per visit (up to 20 visits per year combined with acupuncture) after plan deductible
Acupuncture	10% after deductible (limited to 20 visits per calendar year combined with out-of-network)	50% after deductible (limited to 20 visits per calendar year combined with in-network)
Infertility	50% coinsurance	Not covered
Home Health Care	10% after deductible (coverage limited to 100 visits per calendar year; pre-authorization required)	Not covered
Skilled Nursing or Extended Care Facility	10% after deductible (coverage limited to 100 days per member per year, combined with outof-network; preauthorization required)	10% after deductible at a freestanding skilled nursing facility; 30% after deductible in a skilled nursing unit of a hospital up to $600 per day (coverage limited to 100 days per member per calendar year combined with hospital/free standing skilled nursing facility and in-network)

	Kaiser CDHP	Kaiser HMO
	Details	Details
Annual Deductible
Individual	$1,500 (combined with in-network)	None
Family	$2,800 per individual, up to $3,000 per family (combined with in-network)	None
Plan Accumulation	Calendar Year	Calendar Year
Coinsurance	None	None
Annual Out-of-Pocket Maximum
Individual	$3,000	$1,500
Family	$3,000 individual, up to $6,000 per family	$1,500 per individual, up to $3,000 per family
Deductible Included in Out-of-Pocket Maximum	N/A	N/A
Lifetime Maximum	Unlimited	Unlimited
Non-Network Provider Reimbursement	N/A	N/A
Primary Care Physician Election Required?		Yes
Outpatient Services
Office Visit	10% after deductible	$25 copay
Specialist Office Visit	10% after deductible	$25 copay
Maternity Office Visit (PreNatal Care)	10% after deductible	No charge
Outpatient Surgery	10% after deductible	$25 per procedure
Diagnostic Laboratory & X-Ray	10% after deductible	No charge
Preventive Care
Adult Periodic Exams with Preventive Tests	No charge	No charge
Adult Periodic Exams with Preventive Tests	No charge	No charge
Bridges	No charge	No charge
Inpatient Hospitalization	10% after deductible	$250 per admission
Emergency Room	10% after deductible	$100 per visit, waived if admitted
Prescription Drugs
Deductible	N/A	N/A
Retail
Generic	$10 copay	$10 copay
Brand (Formulary)	$30 copay	$30 copay
Brand (Non-Formulary)	20% coinsurance (not to exceed $200) after deductible	$30 copay (prior authorization required)
Number of Days Supply	30 days	30 days
Mail-Order
Generic	$20 copay	$20 copay
Brand (Formulary)	$60 copay	$60 copay
Brand (Non-Formulary)	$60 copay (prior authorization required)	$60 copay (prior authorization required)
Number of Days Supply	90 days	100 days
Outpatient Rehabilitative Therapy Services
Physical		$25 per visit
Occupational		$25 per visit
Speech		$25 per visit
Other Services and Supplies
Mental Health/Substance Abuse		Inpatient and outpatient covered under general plan design
Durable Medical Equipment		You pay 20% coinsurance per item
Prosthetic Devices		No charge
Chiropractic	$15 per visit (up to 20 visits per year combined with acupuncture) after plan deductible	$15 per visit (coverage limited to 20 visits per calendar year combined with acupuncture)
Acupuncture	$15 per visit (up to 20 visits per year combined with acupuncture) after plan deductible	$15 per visit (coverage limited to 20 visits per calendar year combined with chiropractic)
Infertility		You pay 50% coinsurance (coverage limited to diagnosis & treatment; artificial insemination)
Home Health Care		No charge (coverage limited to 100 visits per calendar year)
Skilled Nursing or Extended Care Facility		No charge (coverage limited to 100 days per benet period)