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
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)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$25 copay
Specialist Visit
$25 copay
Urgent Care
$25 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay (pre-authorization is required)
Specialty
$30 copay
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$60 copay (pre-authorization is required)
Specialty
$30 copay
Plan Documents
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
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
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$4,500
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Rx Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$35 copay (must be approved through exception process)
Specialty
20% up to $100 per script
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$70 copay (must be approved through exception process)
Specialty
20% up to $100 per script
Plan Documents
Contact Information
RxBenefits/CVS Health
Blue Shield/DHS HDHP
Plan Information
Plan Name: Blue Shield/DHS HDHP
Policy Number: 831
Effective Date: 01/01/2025
Network: Blue Shield
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)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$0
Specialist Visit
$0
Urgent Care
$0
Emergency Room
$0
Retail Rx (Up to 30-Day Supply)
Generic
$0
Preferred Brand
$0
Non-Preferred Brand
$0
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0
Preferred Brand
$0
Non-Preferred Brand
$0
Out-of-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
Not covered
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$0
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
RxBenefits/CVS Health