1. No category

A
REEP for Benefits JPA
Summary of PPO & HMO Plans
Effective Date
Renewal Date
Carrier Name
Plan Name
Eligible Class
General Plan Information
Annual Deductible/Individual
Annual Deductible/Family
Coinsurance
Office Visit/Exam
Outpatient Specialist Visit
Annual Out-of-Pocket Limit/Individual
Annual Out-of-Pocket Limit/Family
Lifetime Plan Maximum
Inpatient Hospital Services
Inpatient Hospitalization
Semi-Private Room & Board; Including Services and
Emergency Services
Emergency Room
Mental Health Benefits
Inpatient Care
Outpatient Care
Alcohol Abuse
Inpatient Care
Inpatient Hospitalization
Outpatient Care
Outpatient Services
Substance Abuse
Inpatient Care
Inpatient Hospitalization
Outpatient Care
Outpatient Services
Current
07/01/2015
07/01/2016
Anthem Blue Cross
PPO MVP
Eligible Employees
In-Network Benefits
Out-of-Network Benefits
$5,900
$11,800
100% after the deductible has been satisfied
$35 copay; deductible waived first 3
visits/combined services
$35 copay; deductible waived first 3
visits/combined services
$6,100 Rx not included
$12,200 Rx not included
Unlimited
Current
7/1/2015
7/1/2016
Kaiser Permanente Insurance Company
HMO MVP w/Chiro
Eligible Employees
Schedule of Benefits
$11,800
$23,600
50%
50%
$4,500
$9,000
60%
$50 copay; after deductible
50%
$50 copay; after deductible
$12,700 Rx not included
$25,400 Rx not included
Unlimited
$6,000
$12,000
Unlimited
100% after the deductible has been satisfied
100% after the deductible has been satisfied
0
100%
50%
50%
60% after deductible
60% after deductible
100%
$250 copay; after deductible
100% after the deductible has been satisfied;
subject to utilization review; waived for emergency
50% subject to utilization review; waived for
emergency
60% after deductible
$35 copay; deductible waived for the first 3
visits/combined services
50%
$50 copay; after deductible
70%
50% plus $500 admission fee after the deductible
has been satisfied (waived for emergency).
80% after deductible
$40 copay; deductible waived
50%
$20 copay; deductible waived
100% after the deductible has been satisfied;
subject to utilization review; wavied for emergency
50% subject to utilization review; wavied for
emergency
60% after deductible
$35 copay; deductible waived first 3
50%
$50 copay; after deductible
Keenan & Associates
CA License # 0451271
1 of 2
4/29/2015
A
REEP for Benefits JPA
Summary of PPO & HMO Plans
Effective Date
Renewal Date
Carrier Name
Plan Name
Eligible Class
Prescription Drug Benefits
Prescription Drug Deductible
Annual Out of Pocket Limit Individual
Annual Out of Pocket Limit Family
Generic
Current
07/01/2015
07/01/2016
Anthem Blue Cross
PPO MVP
Eligible Employees
In-Network Benefits
Out-of-Network Benefits
Current
7/1/2015
7/1/2016
Kaiser Permanente Insurance Company
HMO MVP w/Chiro
Eligible Employees
Schedule of Benefits
N/A
N/A
$500
$500
$1,000
$1,000
$19 copay/Tier 1 Pharmacy; $19 copay +
$19 copay/Tier 1 Pharmacy; $19 copay +
$15/Tier 2 Pharmacy provided by ESI (see
$15/Tier 2 Pharmacy provided by ESI (see
www.express-scripts.com for a list of pharmacies) www.express-scripts.com for a list of pharmacies)
$250 per Member/calendar year
Brand (Formulary/Preferred)
$50 copay/Tier 1 Pharmacy; $50 copay +
$50 copay/Tier 1 Pharmacy; $50 copay +
$15/Tier 2 Pharmacy provided by ESI (see
$15/Tier 2 Pharmacy provided by ESI (see
www.express-scripts.com for a list of pharmacies) www.express-scripts.com for a list of pharmacies)
$35 copay; after prescription deductible
Brand (Non-Formulary/Non-preferred)
$19 copay/Tier 1 Pharmacy; $19 copay +
$19 copay/Tier 1 Pharmacy; $19 copay +
$15/Tier 2 Pharmacy provided by ESI (see
$15/Tier 2 Pharmacy provided by ESI (see
www.express-scripts.com for a list of pharmacies) www.express-scripts.com for a list of pharmacies)
Number of Days Supply
Mail Order
Generic
Brand (Formulary/Preferred)
Brand (Non-Formulary/Non-preferred)
Number of Days Supply for Mail Order
Other Services and Supplies
Chiropractic Services
$15 copay; deductible waived
30 days
30 days
30 days
$38 copay provided by Express Scripts
$100 copay provided by Express Scripts
$38 copay provided by Express Scripts
90 days
Not covered
Not covered
Not covered
N/A
$30 copay; deductible waived
$70 copay; after prescription deductible
$35 copay; limited to 24 visits/calendar year;
chiro/phys/occ therapy combined; deductible
waived first 3 visits/combined services; in/out of
network combined
50% limited to 24 visits/calendar year;
chiro/phys/occ therapy combined; in/out of
network combined
$10 copay; 30 visits/calendar year; provided through
American Specialty Health
100 days
Keenan & Associates
CA License # 0451271
2 of 2
4/29/2015