COUNTY OF MARIN

2019 Kaiser Benefit Summary

Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the
plans Evidence of Coverage.

Benefit (In-Network)
Kaiser Plan S Kaiser Plan L
Plan Year Deductible None None
Plan Year Out-of-Pocket Maximum
Individual $1,500 $1,500
Family $3,000 $3,000
Professional Services
Office Visits
Primary Care Provider $25 $5
Specialist $25 $5
Preventive Care No charge No charge
Diagnostic X-ray and Lab No charge No charge
Imaging (MRI, CT/PET scans) No charge No charge
Outpatient Therapy (Speech, Physical, etc.) $25 $5
Acupuncture $25 $5
Chiropractic Services (30 visits per 12-month period) $15 $10
Hospital and Facility Services
Inpatient Hospital and Physician Services No charge No charge
Outpatient Surgery $25 $5
Skilled Nursing Facility (100 days per benefit period) No charge No charge
Mental Health and Substance Abuse
Inpatient Facility No charge No charge
Outpatient Visit
Individual $25 $5
Mental Health: $12 Mental Health: $2
Group
Substance Abuse: $5 Substance Abuse: $2
Emergency Care
Emergency Room $50 (waived if admitted) $50 (waived if admitted)
Ambulance $50 $50
Home Health Care
No charge No charge
(100 visits per Accumulation Period)
Hospice Care No charge No charge
Durable Medical Equipment (DME) 20% 20%
Prescription Drugs
Retail 30-day supply 30-day supply
Generic $10 $5
Brand (Formulary) $25 $5
Brand (Non-Formulary) Same as brand when approved Same as brand when approved
Specialty Drugs $25 $5
Mail Order 100-day supply 100-day supply
Generic $20 $5
Brand (Formulary) $50 $5

2019 Plan Benefits - Side by Side.xlsx Kaiser Benefit Summary 10/15/18

 COUNTY OF MARIN - 2019
Medicare Retirees

Note: This is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Evidence of Coverage.
Current Proposed
Benefit (In-Network)
Anthem PPO UHC
In Network Out of Network In Network Out of Network
Medicare Coordination Medicare Supplement Medicare Replacement
Plan Year Deductible*
Individual $500 N/A
Family $1,000 N/A
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000 $1500 per Medicare member
Family $6,000 $45,000 (Medical only)
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40% $5 Copay $5 Copay
Specialist $20 (deductible waived) 40% $5 Copay $5 Copay
No charge (deductible
Preventive Care 40% No charge No charge
waived)
Diagnostic X-ray and Lab 20% 40% $5 Copay $5 Copay
Imaging (MRI, CT/PET scans) No charge No charge $5 Copay $5 Copay
Outpatient Therapy (Speech, Physical,
20% 40% $5 Copay $5 Copay
etc.)
Acupuncture 20% 40% $5 Copay $5 Copay
(12 visits per year w/ medical necessity) (30 visits per year)
Chiropractic Services 20% 40% $5 Copay $5 Copay
(12 visits per year w/ medical necessity) (30 visits per year)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% $40 No charge No charge
Outpatient Surgery $20 $40 $5 Copay $5 Copay
Skilled Nursing Facility 20% 40% No charge No charge
(100 days per benefit period) (100 days per benefit period)
Mental Health and Substance Abuse
Inpatient Facility 20% 40% No charge No charge
Outpatient Visit $20 (deductible waived) 40% $5 Copay $5 Copay
Emergency Care
$75 Copay (waived if $75 Copay (waived if
Emergency Room $50 (waived if admitted) + 20%
admitted) admitted)
Ambulance 20% No charge No charge
Home Health Care 20% 40% No charge No charge
(100 visits per calendar year) (No limit visit)
Hospice Care 20% No charge No charge
Durable Medical Equipment (DME) 20% 40% 20% 20%
Covered in full up to $2000 annual allowance
Hearing Aids One hearing aid every 3 years (per ear)
(combined)
Prescription Drugs (deductible waived)
Retail 30-day supply 30-day supply***
Generic $5 $5** $5 N/A
Brand (Formulary) $15 %15** $20 N/A
Brand (Non-Formulary) $30 $30** $50 N/A
Specialty Drugs $30 $30** $50 N/A
Mail Order 90-day supply 90-day supply***
Generic $10 N/A $10 N/A
Brand (Formulary) $25 N/A $40 N/A
Brand (Non-Formulary) $45 N/A $100
Specialty Drugs N/A N/A $100 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amount and costs in excess of the
prescription drug maximum allowed amount up to $250 per prescription
***Only available in-network except in case of emergency
 County of Marin - 2019
Non-Medicare Retirees

Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Eviden
Current
Benefit (In-Network)
Anthem PPO
In Network Out of Network
Plan Year Deductible*
Individual $500
Family $1,000
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000
Family $6,000 $45,000
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40%
Specialist $20 (deductible waived) 40%
No charge (deductible
Preventive Care 40%
waived)
Diagnostic X-ray and Lab 20% 40%
Imaging (MRI, CT/PET scans) No charge No charge
Outpatient Therapy (Speech, Physical, etc.) 20% 40%
Acupuncture 20% 40%
(12 visits per year w/ medical necessity)
Chiropractic Services 20% 40%
(12 visits per year w/ medical necessity)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% $40
Outpatient Surgery $20 $40
Skilled Nursing Facility (100 days per benefit period) 20% 40%
Mental Health and Substance Abuse
Inpatient Facility 20% 40%
Outpatient Visit $20 (deductible waived) 40%
Emergency Care
Emergency Room $50 (waived if admitted) + 20%
Ambulance 20%
Home Health Care (100 days per calendar year) 20% 40%
Hospice Care 20%
Durable Medical Equipment (DME) 20% 40%
Hearing Aids One hearing aid every 3 years (per ear)
Prescription Drugs (deductible waived)
Retail 30-day supply
Generic $5 $5**
Brand (Formulary) $15 %15**
Brand (Non-Formulary) $30 $30**
Specialty Drugs $30 $30**
Mail Order 90-day supply
Generic $10 N/A
Brand (Formulary) $25 N/A
Brand (Non-Formulary) $45 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amou
prescription drug maximum allowed amount up to $250 per prescription
***Paid on the plans UCR (Usual, Customary and Reasonable) allowance. Patient responsible for anything over UCR
and limitations, please refer to the plans Evidence of Coverage.
Proposed
Teamsters Anthem PPO
In Network Out of Network

$250
$500

Unlimited

$20 (deductible waived) 40%***

$20 (deductible waived) 40%***

No charge Not covered

20% 40%***
20% 40%***
20% 40%***
20% 40%***
(15 visits per year w/ medical necessity)
20% S
(40 visits per year w/ medical necessity)

20% 40%***
20% 50%***
20% 40%***

20% 50%***
20% 50%***

20% 50%***
20% 50%***
20% 40%***
20% 40%***
20% 40%***
$1,000 every 3 years (per ear)

30-day supply
$10
$20
$20
N/A
90-day supply
$10
$20
$20
ining prescription drug maximum allowed amount and costs in excess of the

onsible for anything over UCR

 County of Marin - 2019
Non-Medicare Retirees

Note: this is only a summary of benefits. For a detailed description of benefits, exclusions, and limitations, please refer to the plans Eviden
Current
Benefit (In-Network)
Anthem PPO

In Network Out of Network

Plan Year Deductible*

Individual $500
Family $1,000
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000
Family $6,000 $45,000
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40%
Specialist $20 (deductible waived) 40%

No charge (deductible
Preventive Care 40%
waived)

Diagnostic X-ray and Lab 20% 40%

Imaging (MRI, CT/PET scans) No charge No charge

Outpatient Therapy (Speech, Physical, etc.) 20% 40%

Acupuncture 20% 40%

(12 visits per year w/ medical necessity)
Chiropractic Services 20% 40%
(12 visits per year w/ medical necessity)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% $40
Outpatient Surgery $20 $40
Skilled Nursing Facility 20% 40%
(100 days per benefit period)
Mental Health and Substance Abuse
Inpatient Facility 20% 40%
Outpatient Visit $20 (deductible waived) 40%
Emergency Care
Emergency Room $50 (waived if admitted) + 20%
Ambulance 20%
Home Health Care 20% 40%
(100 visits per calendar year)
Hospice Care 20%

Durable Medical Equipment (DME) 20% 40%

Hearing Aids One hearing aid every 3 years (per ear)

Prescription Drugs (deductible waived)
Retail 30-day supply
Generic $5 $5**
 Brand (Formulary) $15 %15**
Brand (Non-Formulary) $30 $30**
Specialty Drugs $30 $30**
Mail Order 90-day supply
Generic $10 N/A
Brand (Formulary) $25 N/A
Brand (Non-Formulary) $45 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amou
prescription drug maximum allowed amount up to $250 per prescription
s, and limitations, please refer to the plans Evidence of Coverage.
Proposed
WHA

In Network Out of Network

N/A N/A
N/A N/A

$1,500 N/A
$3,000 N/A

$15 Not covered

$15 Not covered

No charge Not covered

$15 Not covered

$15 Not covered

$15 (must be deemed

Not covered
medically necessary)

$15
Not covered
(20 visits per year)
$15
Not covered
(20 visits per year)

No charge Not covered

$15 Not covered
No charge Not covered
(100 days per calendar year)

No charge Not covered

No charge Not covered

$75 (waived if admitted) Not covered

No charge Not covered
100%
Not covered
(100 days per calendar year)
100% Not covered
20% (must be deemed
medically necessary and Not covered
preauthorized)

30-day supply
$5 Not covered
 $20 Not covered
$20 Not covered
$50 Not covered
90-day supply
$10 Not covered
$40 Not covered
$100 Not covered

maining prescription drug maximum allowed amount and costs in excess of the
 County of Marin - Retirees 2019

Current Anthem PPO

Benefit (In-Network)
In Network Out of Network

Plan Year Deductible

Individual $500
Family $1,000
Plan Year Out-of-Pocket Maximum
Individual $3,000 $15,000
Family $6,000 $45,000
Professional Services
Office Visits
Primary Care Provider $20 (deductible waived) 40%
Specialist $20 (deductible waived) 40%
No charge (deductible
Preventive Care 40%
waived)
Diagnostic X-ray and Lab 20% 40%
Imaging (MRI, CT/PET scans) No charge No charge
Outpatient Therapy (Speech, Physical, etc.) 20% 40%
Acupuncture 20% 40%
(12 visits per year w/ medical necessity)
Chiropractic Services 20% 40%
(12 visits per year w/ medical necessity)
Hospital and Facility Services
Inpatient Hospital and Physician Services 20% 40%
Outpatient Surgery 20% 40%
Skilled Nursing Facility (100 days per benefit period) 20% 40%
Mental Health and Substance Abuse
Inpatient Facility 20% 40%
Outpatient Visit
Individual
$20 (deductible waived) 40%
Group

Emergency Care
Emergency Room $50 (waived if admitted) + 20%
Ambulance 20%
Home Health Care
20% 40%
(100 visits per Accumulation Period)
Hospice Care 20%
Durable Medical Equipment (DME) 20% 40%
Hearing Aids One hearing aid every 3 years (per ear)
Prescription Drugs (deductible waived)
Retail 30-day supply
Generic $5 $5**
Brand (Formulary) $15 %15**
Brand (Non-Formulary) $30 $30**
Specialty Drugs $30 $30**
Mail Order 90-day supply
Generic $10 N/A
Brand (Formulary) $25 N/A
Brand (Non-Formulary) $45 N/A
*All benefits are after deductible unless otherwise noted.
** For out of network pharmacies, members pay the above copay plus 50% of the remaining prescription drug maximum allowed amou
prescription drug maximum allowed amount up to $250 per prescription
etirees 2019

Current Kaiser

Kaiser Plan S Kaiser Plan L

None None
None None

$1,500 $1,500
$3,000 $3,000

$25 $5
$25 $5

No charge No charge

No charge No charge
No charge No charge
$25 $5
$25 $5

$15 $10
(30 visits per 12-month period)

No charge No charge
$25 $5
No charge No charge

No charge No charge

$25 $5
Mental Health: $12 Mental Health: $2
Substance Abuse: $5 Substance Abuse: $2

$50 (waived if admitted) $50 (waived if admitted)

$50 $50

No charge No charge

No charge No charge
20% 20%

30-day supply 30-day supply

$10 $5
$25 $5
Same as brand when approved Same as brand when approved
$25 $5
100-day supply 100-day supply
$20 $5
$50 $5
 Same as brand when approved Same as brand when approved

g prescription drug maximum allowed amount and costs in excess of the