Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Kaiser HMO
Plan Information
Plan Name: Kaiser HMO
Policy Number: 7347
Effective Date: 01/01/2025
Network: Kaiser HMO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/Up to $3,000
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$5 copay
Urgent Care
$5 copay
Emergency Room
$50 copay
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Formulary
$5 copay
Non-Formulary
$5 copay (Non-preferred brand drugs must be approved through exception process)
Mail-Order Rx (Up to 100-Day Supply)
Generic
$5 copay
Formulary
$5 copay
Non-Formulary
$5 copay (Non-preferred brand drugs must be approved through exception process)
Plan Documents
Year Carrier Document Plan Name
Contact Information
Blue Shield/DHS EPO
Plan Information
Plan Name: Blue Shield/DHS EPO
Policy Number: 831
Effective Date: 01/01/2025
Network: Blue Shield/DHS EPO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$4,500
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$10 copay
Urgent Care
$10 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$10
Formulary
$25
Non-Formulary
$40
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Formulary
$50
Non-Formulary
$80
Plan Documents
Year Carrier Document Plan Name
Contact Information
Blue Shield/DHS PPO
Plan Information
Plan Name: Blue Shield/DHS PPO
Policy Number: 831
Effective Date: 01/01/2025
Network: Blue Shield/DHS PPO
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
10% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$5
Formulary
$15
Non-Formulary
$35
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10
Formulary
$30
Non-Formulary
$70
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% of eligible cost after copays
Formulary
50% of eligible cost after copays
Non-Formulary
50% of eligible cost after copays
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Formulary
Not covered
Non-Formulary
Not covered
Plan Documents
Year Carrier Document Plan Name
Contact Information
Blue Shield/DHS HDHP
Plan Information
Plan Name: Blue Shield/DHS HDHP
Policy Number: 831
Effective Date: 01/01/2025
Network: Blue Shield/DHS HDHP
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
10% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Prescription Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Generic
$5
Formulary
$15
Non-Formulary
$35
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10
Formulary
$30
Non-Formulary
$70
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$100 copay + 10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% of eligible cost after copays
Formulary
50% of eligible cost after copays
Non-Formulary
50% of eligible cost after copays
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Formulary
Not covered
Non-Formulary
Not covered
Plan Documents
Year Carrier Document Plan Name