Attachment A A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Kaiser Plan Name Western Health Advantage HMO HSA $1800 Deductible HMO HSA $1800 Deductible Annual Deductible/Individual $0 copay $1,800 $0 copay $1,800 Annual Deductible/Family $0 copay $3,600 $0 copay $3,600 N/A 100% 100% 100% Office Visit/Exam $10 copay No Charge After Deductible $15 copay No Charge After Deductible Outpatient Specialist Visit General Plan Information Coinsurance $10 copay No Charge After Deductible $15 copay No Charge After Deductible Annual Out-of-Pocket Limit/Individual $1,500 $1,800 $1,500 $1,800 Annual Out-of-Pocket Limit/Family $3,000 $3,600 $2,500 $3,600 N/A Yes N/A Yes Unlimited Unlimited Unlimited Unlimited Yes Yes Yes Yes Deductible Included in Out-of-Pocket Limits Lifetime Plan Maximum Primary Care Physician Election Required Outpatient Services Preventive Services Well-Child Care $0 copay No Charge - Deductible Waived $0 copay No Charge - Deductible Waived Immunizations $0 copay No Charge - Deductible Waived $0 copay No Charge - Deductible Waived Well Woman Exams $0 copay No Charge - Deductible Waived $0 copay No Charge - Deductible Waived Mammograms $0 copay No Charge - Deductible Waived $0 copay No Charge - Deductible Waived Adult Periodic Exams with Preventive Tests $0 copay No Charge - Deductible Waived $0 copay No $0 copay No Charge After Deductible $0 copay No Charge After Deductible - Deductible waived for Preventive screenings $0 copay No Charge, Deductible Waived $0 copay No Charge - Deductible Waived $0 copay No Charge After Deductible $0 copay No Charge After Deductible Yes Yes Yes Yes $0 copay No Charge After Deductible $0 copay No Charge After Deductible $10 copay per procedure No Charge After Deductible $100 copay per procedure in an outpatient surgery facility; $15 copay per procedure in an office setting No Charge After Deductible $75 copay waived if admitted No Charge After Deductible $100 copay (waived if admitted) No Charge After Deductible Air $0 copay No Charge After Deductible $0 copay No Charge After Deductible Ground $0 copay No Charge After Deductible $0 copay No Charge After Deductible Diagnostic X-Ray and Lab Tests Maternity Care Pregnancy and Maternity Care (Pre-Natal Care) Inpatient Hospital Services Inpatient Hospitalization Pre-Authorization Required Services and Semi-Private Roomof&Services Board; Including Supplies Surgical Services Outpatient Facility Charge Emergency Services Emergency Room Ambulance Keenan Associates - CA License # 0451271 Page 1 of 6 A Attachment A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Kaiser Plan Name Western Health Advantage HMO HSA $1800 Deductible HMO HSA $1800 Deductible $10 copay No Charge After Deductible $20 copay No Charge After Deductible $0 copay $10 copay individual therapy; $5 copay group therapy No Charge After Deductible 100% covered (prior authorization required) No Charge After Deductible No Charge After Deductible $15 copay No Charge After Deductible Inpatient Hospitalization $0 copay No Charge After Deductible $0 copay (prior authorization required) No Charge After Deductible Inpatient Detoxification Services $0 copay No Charge After Deductible $0 copay (prior authorization required) No Charge After Deductible $10 copay individual therapy; $5 copay group therapy No Charge After Deductible $15 copay No Charge After Deductible Generic $10 copay No Charge After Deductible $10 copay No Charge After Deductible Brand (Formulary/Preferred) $10 copay No Charge After Deductible $20 copay No Charge After Deductible Not covered No Charge After Deductible $30 copay No Charge After Deductible 100 days 30 days 30 days 30 days Generic $10 copay No Charge After Deductible $20 copay No Charge After Deductible Brand (Formulary/Preferred) $10 copay No Charge After Deductible $40 copay No Charge After Deductible Not covered Not covered $60 copay No Charge After Deductible 100 days 100 days Up to 90 days 90 days $0 copay No Charge After Deductible - Allowed up to $2500/year - In accordance with DME formulary 20% copay No Charge After Deductible Home Health Care $0 copay Up to 100 visits/calendar year No Charge After Deductible - Up to 100 visits/calendar year $0 copay Limited to 100 visits per cal year No Charge After Deductible - Limited to 100 visits per calendar year Skilled Nursing or Extended Care Facility $0 copay Up to 100 days/benefit period No Charge After Deductible - Up to 100 days/benefit period $0 copay Limited to 100 days per cal year No Charge After Deductible - Limited to 100 days per calendar year $0 copay $10 copay Up to 30 visits per year $10 copay Must be referred by physician No Charge After Deductible $0 copay $15 copay - Limited to 20 medically necessary visits per cal year $15 copay - Limited to 20 medically necessary visits per cal year No Charge After Deductible $15 copay (does not apply to annual out of pocket maximum) $15 copay (does not apply to annual out of pocket maximum) Urgent Care Urgent Care Facility Mental Health Benefits Inpatient Care Outpatient Care Substance Abuse Outpatient Care Outpatient Services Prescription Drug Benefits Brand (Non-Formulary/Non-preferred) Number of Days Supply Mail Order Brand (Non-Formulary/Non-preferred) Number of Days Supply for Mail Order Other Services and Supplies Durable Medical Equipment & Prosthetic Devices Hospice Care Chiropractic Services Acupuncture Not covered Not covered Keenan Associates - CA License # 0451271 Page 2 of 6 A Attachment A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Kaiser Plan Name Western Health Advantage HMO HSA $1800 Deductible HMO HSA $1800 Deductible Hearing $0 copay No Charge - Deductible Waived $0 - For preventive screenings only No Charge After Deductible Not covered Not covered Not covered Not covered Physical $10 copay No Charge After Deductible $15 copay No Charge After Deductible Occupational $10 copay No Charge After Deductible $15 copay No Charge After Deductible Speech $10 copay No Charge After Deductible $15 copay No Charge After Deductible Classified & Management All Employees All Employees $538.45 $1,076.90 $1,399.97 $645.28 $1,286.80 $1,819.27 $442.56 $885.11 $1,252.44 Screening Aid(s) Outpatient Rehabilitative Therapy Services Monthly Premium Rates Certificated Employee Only Employee + 1 Family $675.68 $1,351.35 $1,912.17 Classified & Management $659.01 $1,318.02 $1,713.42 Certificated $550.55 $1,101.10 $1,558.05 Keenan Associates - CA License # 0451271 Page 3 of 6 A Attachment A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Sutter Health Plus Plan Name HMO HSA $1500 Deductible Annual Deductible/Individual $0 copay $1,500 Annual Deductible/Family $0 copay $3,000 General Plan Information Coinsurance 100% 100% Office Visit/Exam $10 copay No Charge After Deductible Outpatient Specialist Visit $10 copay No Charge After Deductible $750 $1,500 $1,500 $3,000 Annual Out-of-Pocket Limit/Individual Annual Out-of-Pocket Limit/Family Deductible Included in Out-of-Pocket Limits Lifetime Plan Maximum Primary Care Physician Election Required Outpatient Services N/A Yes Unlimited Unlimited Yes Yes Preventive Services Well-Child Care $0 copay No Charge - Deductible Waived Immunizations $0 copay No Charge - Deductible Waived Well Woman Exams $0 copay No Charge - Deductible Waived Mammograms $0 copay No Charge - Deductible Waived $0 copay $0 copay $50 copay for advanced imaging No Charge - Deductible Waived No Charge After Deductible - Deductible waived for Preventive screenings $0 copay No Charge - Deductible Waived $0 copay No Charge After Deductible Adult Periodic Exams with Preventive Tests Diagnostic X-Ray and Lab Tests Maternity Care Pregnancy and Maternity Care (Pre-Natal Care) Inpatient Hospital Services Inpatient Hospitalization Pre-Authorization Required Services and Semi-Private Roomof&Services Board; Including Supplies Surgical Services Yes Yes $0 copay No Charge After Deductible $0 copay No Charge After Deductible $30 copay (waived if admitted) No Charge After Deductible Air $30 copay per trip No Charge After Deductible Ground $30 copay per trip No Charge After Deductible Outpatient Facility Charge Emergency Services Emergency Room Ambulance Keenan Associates - CA License # 0451271 Page 4 of 6 A Attachment A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Sutter Health Plus Plan Name HMO HSA $1500 Deductible $15 copay (waived if admitted) 100% covered after cal year deductible 100% covered (prior authorization required) No Charge After Deductible $10 copay No Charge After Deductible Inpatient Hospitalization $0 copay (prior authorization required) No Charge After Deductible Inpatient Detoxification Services $0 copay (prior authorization required) No Charge After Deductible $10 copay No Charge After Deductible Generic $5 copay No Charge After Deductible Brand (Formulary/Preferred) $20 copay No Charge After Deductible Brand (Non-Formulary/Non-preferred) $40 copay No Charge After Deductible 30 days 30 days Generic $10 copay No Charge After Deductible Brand (Formulary/Preferred) $40 copay No Charge After Deductible Brand (Non-Formulary/Non-preferred) $80 copay No Charge After Deductible Up to 100 days 90 days Urgent Care Urgent Care Facility Mental Health Benefits Inpatient Care Outpatient Care Substance Abuse Outpatient Care Outpatient Services Prescription Drug Benefits Number of Days Supply Mail Order Number of Days Supply for Mail Order Other Services and Supplies Durable Medical Equipment & Prosthetic Devices Home Health Care Skilled Nursing or Extended Care Facility Hospice Care Chiropractic Services Acupuncture $0 copay (prior authorization required) $0 copay Limited to 100 visits per cal year $0 copay Limited to 100 days per cal year No Charge After Deductible No Charge After Deductible - Limited to 100 visits per calendar year No Charge After Deductible - Limited to 100 days per calendar year $0 copay $10 copay - Limited to 30 visits per calendar year No Charge After Deductible Not covered Not covered Not covered Keenan Associates - CA License # 0451271 Page 5 of 6 A Sacramento City Unified School District - Effective January 1, 2015 Kaiser/WHA/Sutter - Plan/Rate Comparison - Active Employees & Early Retirees Attachment A Sutter Health Plus Plan Name HMO HSA $1500 Deductible $0 copay for preventive screenings No Charge After Deductible Not covered Not covered Physical $0 copay No Charge After Deductible Occupational $0 copay No Charge After Deductible Speech $0 copay No Charge After Deductible All Employees All Employees $636.49 $1,272.98 $1,801.27 $482.22 $964.44 $1,364.68 Hearing Screening Aid(s) Outpatient Rehabilitative Therapy Services Monthly Premium Rates Employee Only Employee + 1 Family Keenan Associates - CA License # 0451271 Page 6 of 6
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