Transcription
EmployeeBENEFITSGuide2022
EmployeeBenefits Guide2022General Information1.Introduction and Eligibility2.When You Can EnrollCore Benefits3.Medical20.2022 CalPERS – PPO Basic Plans (Classified Only)16.2022 CalPERS – HMO & PPO Basic23.DentalPlans (Classified Only)24.Vision2022 CalPERS – EPO & HMO Basic26.Kaiser HSA for HDHPPlans (Classified Only)32.WHA HSA for HDHP17.Other Benefits33.Basic Life & AD&D37.Building Blocks - Colonial Life34.Employee Assistance Program38.Flexible Spending Accounts (FSA)35.BenefitBridge48.Contact InformationMiscellaneous39.Important NoticesIf you (and/or your dependents) have Medicare or you will become eligible for Medicarein the next 12 months, a Federal law gives you more choices about your prescription drug coverage.Please see page 43 for more details.The information in this brochure is a general outline of the benefits offered under Washington USD’s benefits program. Specific details and plan limitationsare provided in the Summary Plan Descriptions (SPD), which is based on the official Plan Documents that may include policies, contracts and planprocedures. The SPD and Plan Documents contain all the specific provisions of the plans. In the event that the information in this brochure differs fromthe Plan Documents, the Plan Documents will prevail.Washington Unified School District, West Sacramentoi
Introduction and EligibilityFlexible Solutions ForYour Benefits NeedsWe consider our employee benefits program to be one ofour most important investments. Because we recognize thevalue our employees bring to our district, we are committedto providing you with a complete benefits program as partof your total compensation.This guide has been prepared to assist you in makinginformed decisions regarding your employee benefits.We urge you to read this guide carefully and keep it as areference. If you are well informed you will be better ableto make the benefit choices that best meet your needs.PleasecontacttheBenefitsDepartmentat 916.375.7604 Ext. 7 (Ext. 4001 if calling internally)if you have any questions regarding your employeebenefits package.Thank you.Who’s Eligible?EmployeesPlease contact the Washington Unified School DistrictBenefits Department to inquire about eligibility guidelines.Eligible DependentsYour eligible dependents include your legally marriedspouse, domestic partner, and children (includingstepchildren and adopted children) up to age 26. Age limitsmay apply to dependents enrolled as full-time students.Coverage may be available for a mentally or physicallydisabled child who is age 26 or older. Requirements forsuch coverage and documentation of disability depend onthe insurance carrier.For more information, contact the Benefits Department at916.375.7604 Ext. 7 (Ext. 4001 if calling internally)Washington Unified School District, West Sacramento1
When You Can EnrollNew Hires/NewlyEligible for BenefitsWhen you are first hired or become eligible for benefits,you have 30 days to enroll for benefits. If you do notenroll within that time period you will not be eligible forbenefits until the next Open Enrollment, unless you have aChange in Status.Open EnrollmentDuring Open Enrollment you will have the opportunity tomake changes to your benefit elections. You must enrollby the Open Enrollment deadline for your benefits to beeffective January 1st. Except for a Change in Status, youwill not be able to change your elections until the nextyear’s Open Enrollment.Change in StatusIf you have a Change in Status, you may be able tochange your benefits before the next Open Enrollment.You must notify the Benefits Department within 30 daysof the change.* If you meet the deadline, changes will beeffective on the event date.*Change in Status events include: Change in marital status Change in dependents Change in benefits eligibility for you, your spouseor dependent Change in employment for you, your spouse ordependent Change in work schedule for you or your spouse Gaining other coverage through your spouse Loss of other coverage for your dependent Change in residence causing loss of coverage Federal and state family medical leave, if qualified Medicare or Medicaid entitlement for you, yourspouse or dependent Qualified Medical Child Support Order (QMCSO)Contact the Benefits Department at 916.375.7604 Ext. 7 (Ext. 4001 if calling internally)for a complete explanation of qualifying family status change.2Washington Unified School District, West Sacramento
MedicalEligible Employees and Early RetireesWUSD employees can choose from various medical plans. The medical plans provide comprehensive coverage but are differentin how they are designed. Review the benefit summaries featured to understand the differences between the plans. Medicareeligible Retirees receive vision benefits from Kaiser and Health Net.You decide which plan best meets your needs Certificated:–Kaiser Permanente HMO – 20 office visit copay plan–Kaiser Permanente HMO HSA –HDHP #9835 plan–United Healthcare PPO –BPFJ PPO 400 Deductible–Western Health Advantage HMO – 20 office copay plan–Western Health Advantage HMO HSA –1800/0 planWhen enrolling in an HMO, you must select a primary carephysician who will manage your care and refer you to aspecialist when it is needed. Most services are covered ata 100% after you pay a copayment.Health Saving AccountYour HSA-compatible plan is a high deductible healthplan (HDHP) that enables you, as a consumer, to manageyour individual or family health care expenditures. Thishighly-rated plan provides you and your family medicalservices at lower premiums. Your HSA is the financialcomponent (the account that holds your funds) providing atax-free way to save and pay for qualified medical expenses.The combined strength of your HSA-compatible plan andthe funds in your HSA provides you peace of mind aboutyour current and future health care needs. This plan hasbeen updated to include member maximums within familycoverage. Please refer to pages 5 & 10 for the summaryof benefits.Superior Vision PlanAll eligible employees have two Superior Vision plans fromwhich to choose. There is a base plan and buy-up planoption, and both offer comprehensive coverage throughthe Superior Vision National Network of providers. SuperiorVision also offers a number of non-covered services ata discount.Post-65 Retirees(Must have Medicare Parts A & B and live within 30 miles ofa Health Net HMO medical group or Kaiser Facility.)Visit Kaiser Permanente:www.kp.orgVisit Western Health Advantage:www.westernhealth.comYou have the choice to select one plan from thefollowing: Kaiser Permanente HMO Senior Advantage(California Only) Health Net HMO Seniority Plus (California Only)Visit United Healthcare:www.uhc.comVisit Superior Vision:www.superiorvision.comVisit Health Net:www.healthnet.comWashington Unified School District, West Sacramento3
Medical (continued)Eligible Employees & Early RetireesKaiser PermanentePlan BenefitsLifetime MaximumMaximum Out of PocketHMO TraditionalCertificated Employees & Early RetireesUnlimited 1,500 Individual/ 3,000 FamilyPreventive Services Routine PhysicalNo charge Well Baby/ImmunizationsNo chargePhysician/Diagnostic Services Office Visits 20 copay Lab & X-ray & Diagnostic TestNo charge Prenatal/Postnatal Office VisitsNo chargeHospital Services Semi-Private Room & Board 250 copay Outpatient Surgery 100 copay Emergency Room (waived if admitted) 125 copay Urgent Care 20 copayOther Services Ambulance 100 copay Durable Medical EquipmentNo chargePrescription Drugs Plan Pharmacy (Up to a 30-day supply)– Generic 10 copay– Brand 30 copay Mail-order (Up to a 100-day supply)– Generic 20 copay– Brand 60 copayThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.4Washington Unified School District, West Sacramento
Medical (continued)Kaiser PermanentePlan BenefitsHMO HDHP w/ HSACertificated Employees & Early Retirees*See page 26 for setting up a HSA account through HSA Authority.General Plan Information Annual Deductible/Individual Annual Deductible/Family 1,800 per calendar year 2,800 (Each member in a family of two or more members) 3,600 (Entire family of two or more members) per calendar year Coinsurance100% after calendar year deductible Office Visit/Exam100% after calendar year deductible Outpatient Specialist Visit100% after calendar year deductible 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 3,600 per calendar year 3,600 (Each member in a family of two or more members) 7,200 (Entire family of two or more members) per calendar yearYesUnlimitedYesOutpatient ServicesPreventive Services Well-Child Care100% (deductible does not apply) Immunizations100% (deductible does not apply) Well Woman Exams100% (deductible does not apply) Mammograms100% (deductible does not apply) Adult Periodic Exams with Preventive Tests Diagnostic X-Ray and Lab Tests100% (deductible does not apply)100% after calendar year deductibleMaternity Care Pregnancy and Maternity Care (Pre-Natal Care)100% (deductible does not apply)Inpatient Hospital Services Inpatient Hospitalization Pre-Authorization of Services Required Semi-Private Room & Board; Including Services and Supplies100% after calendar year deductibleYes100% after calendar year deductibleSurgical Services Outpatient Facility Charge100% after calendar year deductibleEmergency Services Emergency Room100% after calendar year deductibleAmbulance Air100% after calendar year deductible Ground100% after calendar year deductibleUrgent Care Urgent Care Facility100% after calendar year deductibleMental Health Benefits Inpatient Care100% after calendar year deductible Outpatient Care100% after calendar year deductibleThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.Washington Unified School District, West Sacramento5
Medical (continued)Kaiser PermanentePlan BenefitsHMO HDHP w/ HSACertificated Employees & Early Retirees*See page 26 for setting up a HSA account through HSA Authority.Substance AbuseInpatient Care Inpatient Hospitalization100% after calendar year deductible Inpatient Detoxification Services100% after calendar year deductibleOutpatient Care Outpatient Services100% after calendar year deductiblePrescription Drug Benefits Prescription Drug DeductibleSubject to plan deductible Prescription Drug Annual Out-of-Pocket Limit/IndividualWill accrue to annual OOP Max Prescription Drug Annual Out-of-Pocket Limit/FamilyWill accrue to annual OOP Max Generic 10 copay after calendar year deductible Preferred Specialty 30 copay after calendar year deductible Brand (Formulary/Preferred) 30 copay after calendar year deductible Brand (Non-Formulary/Non-preferred) 30 copay after calendar year deductible Number of Days Supply30 daysMail Order Brand (Formulary/Preferred) 60 copay after calendar year deductible Brand (Non-Formulary/Non-preferred) 60 copay after calendar year deductible Number of Days Supply for Mail Order100 daysOther Services and Supplies Durable Medical Equipment & Prosthetic Devices100% after calendar year deductible Home Health Care100% after calendar year deductible Skilled Nursing or Extended Care Facility100% after calendar year deductible Hospice Care100% after calendar year deductible Chiropractic Services AcupunctureNot coveredMust be referredHearing Screening Aid(s)100% after calendar year deductibleNot coveredInfertility DiagnosisSee Plan Certificate TreatmentSee Plan CertificateOutpatient Rehabilitative Therapy Services Physical100% after calendar year deductible Occupational100% after calendar year deductible Speech100% after calendar year deductibleThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.6Washington Unified School District, West Sacramento
Medical (continued)Eligible Employees & Early RetireesWestern Health AdvantagePlan BenefitsLifetime MaximumMaximum Out of PocketHMO 250 MHPCertificated Employees & Early RetireesUnlimited 1,500 Individual/ 2,500 FamilyPreventive Services Routine PhysicalNo charge Well Baby/ImmunizationsNo chargePhysician/Diagnostic Services Office Visits (including specialists) 20 copay Lab & X-ray & Diagnostic TestNo charge Prenatal/Postnatal Office VisitsNo chargeHospital Services Semi-Private Room & Board 250 copay Outpatient Surgery (facility) 100 copay Emergency Room (waived if admitted) 125 copay Urgent Care 35 copayOther Services Ambulance Durable Medical EquipmentNo charge if medically necessary20% copay when medically necessary*Prescription Drugs Plan Pharmacy (Up to a 30-day supply)– Generic 10 copay– Brand 30 copay– Non-Formulary 50 copay Mail-order (Up to a 90-day supply)– Generic 25 copay– Brand 75 copay– Non-Formulary 125 copay*Copayments do not contribute to the out-of-pocket maximum (unless required for the management or treatment diabetes or pediatric asthma supplies andequipment). Percentage copayment amounts are based on WHA’s contracted rate.The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.Washington Unified School District, West Sacramento7
Medical (continued)Western Health AdvantagePlan BenefitsHMO HDHP w/HSA CertificatedEmployees & Early Retirees* See page 32 for setting up a HSA account through Health Equity.General Plan Information Annual Deductible/Individual Annual Deductible/Family 1,800 per calendar year 2,800 (Each member of a family of two or more members) 3,600 (Entire family of two or more members) per calendar year Coinsurance100% after calendar year deductible Office Visit/Exam100% after calendar year deductible Outpatient Specialist Visit100% after calendar year deductible 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 3,600 per calendar year 3,600 (Each member of a family of two or more members) 7,200 (Entire family of two or more members) per calendar yearYesUnlimitedYesOutpatient ServicesPreventive Services Well-Child Care100% (deductible doesn’t apply) Immunizations100% (deductible doesn’t apply) Well Woman Exams100% (deductible doesn’t apply) Mammograms100% (deductible doesn’t apply) Adult Periodic Exams with Preventive Tests100% (deductible doesn’t apply) Diagnostic X-Ray and Lab Tests100% after calendar year deductibleMaternity Care Pregnancy and Maternity Care (Pre-Natal Care)100% (deductible doesn’t apply)Inpatient Hospital Services Inpatient Hospitalization Pre-Authorization of Services Required Semi-Private Room & Board; Including Services and Supplies100% after calendar year deductibleYes100% after calendar year deductibleSurgical Services Outpatient Facility Charge100% after calendar year deductibleEmergency Services Emergency Room100% after calendar year deductibleAmbulance Air100% after calendar year deductible Ground100% after calendar year deductibleUrgent Care Urgent Care Facility100% after calendar year deductibleMental Health Benefits Inpatient Care100% after calendar year deductible Outpatient Care100% after calendar year deductibleThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.8Washington Unified School District, West Sacramento
Medical (continued)Western Health AdvantagePlan BenefitsHMO HDHP w/HSA CertificatedEmployees & Early Retirees* See page 32 for setting up a HSA account through Health Equity.Substance Abuse Inpatient Care– Inpatient Hospitalization100% after calendar year deductible– Inpatient Detoxification Services100% after calendar year deductible Outpatient Care– Outpatient Services100% after calendar year deductiblePrescription Drug Benefits Prescription Drug DeductibleSubject to plan deductible Prescription Drug Annual Out-of-Pocket Limit/IndividualWill accrue to annual OOP Maximum Prescription Drug Annual Out-of-Pocket Limit/FamilyWill accrue to annual OOP Maximum– Generic100% after calendar year deductible– Preferred Generic– Preferred Specialty– Non-preferred Specialty– Brand (Formulary/Preferred) 30 copay after calendar year deductible– Brand (Non-Formulary/Non-preferred) 50 copay after calendar year deductible Number of Days Supply30 daysMail Order Mail Order Mandatory– GenericN/A100% after calendar year deductible– Preferred Generic– Preferred Specialty– Non-preferred Specialty– Brand (Formulary/Preferred) 75 copay after calendar year deductible– Brand (Non-Formulary/Non-preferred) 125 copay after calendar year deductible Number of Days Supply for Mail Order90 daysOther Services and Supplies Durable Medical Equipment & Prosthetic Devices100% after calendar year deductible Home Health Care100% after calendar year deductible Skilled Nursing or Extended Care Facility100% after calendar year deductible Hospice Care100% after calendar year deductible Chiropractic Services 15 copay; 20 visits per calendar year Acupuncture 15 copay; 20 visits per calendar yearHearing Screening100% after calendar year deductible Aid(s)Infertility DiagnosisSee Plan Certificate TreatmentSee Plan CertificateOutpatient Rehabilitative Therapy Services Physical100% after calendar year deductible Occupational100% after calendar year deductible Speech100% after calendar year deductibleThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.Washington Unified School District, West Sacramento9
Medical (continued)United HealthcarePlan BenefitsPPO – Plan BPFJCertificated Employees & Early RetireesIn-networkOut-of-network Annual Deductible/Individual 400 400 Annual Deductible/Family 800 800 Coinsurance10%40% Office Visit/Exam 20 copay40% after deductible Outpatient Specialist Visit 30 copay40% after deductible Annual Out-of-Pocket Limit/Individual 2,000 4,000 Annual Out-of-Pocket Limit/Family 4,000 8,000 Well-Child CareNo charge40% after deductible ImmunizationsNo charge40% after deductible Well Woman ExamsNo charge40% after deductible MammogramsNo charge40% after deductible Adult Periodic Exams with Preventive TestsNo charge40% after deductibleNo charge; advanced imaging10% after deductible40% after deductibleNo charge40% after deductible Inpatient Hospitalization10% after deductible40% after deductible Semi-Private Room & Board; Including Services and Supplies10% after deductible40% after deductible10% after deductible40% after deductible,OON-limits apply 250 copay per visit 250 copay per visit10% after deductible10% after deductible 50 copay40% after deductible10% after deductible40% after deductible 20 copay40% after deductible Inpatient Hospitalization10% after deductible40% after deductible Inpatient Detoxification Services10% after deductible40% after deductible 20 copay40% after deductibleGeneral Plan InformationOutpatient ServicesPreventive Services Diagnostic X-Ray and Lab TestsMaternity Care Pregnancy and Maternity Care (Pre-Natal Care)Inpatient Hospital ServicesSurgical Services Outpatient Facility ChargeEmergency Services Emergency RoomAmbulance GroundUrgent Care Urgent Care FacilityMental Health Benefits Inpatient Care Outpatient Care Substance AbuseInpatient CareOutpatient Care Outpatient ServicesThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.10Washington Unified School District, West Sacramento
Medical (continued)United HealthcarePlan BenefitsPPO – Plan BPFJCertificated Employees & Early RetireesPrescription Drug Benefits Prescription Drug DeductibleN/AN/A Prescription Drug Annual Out-of-Pocket Limit/IndividualWill accrue to annual OOP MaxWill accrue to annual OOP Max Prescription Drug Annual Out-of-Pocket Limit/FamilyWill accrue to annual OOP MaxWill accrue to annual OOP Max Generic 7 copay 7 copayMatches Retail In-NetworkNot covered Brand (Formulary/Preferred) 20 copay 20 copay Brand (Non-Formulary/Non-preferred) 35 copay 35 copay31 days31 days Generic 0 copayNot covered Brand (Formulary/Preferred) 40 copayNot covered Brand (Non-Formulary/Non-preferred) 70 copayNot covered Number of Days Supply for Mail Order90 days90 days10% after deductibleNot covered Preferred Specialty Number of Days SupplyMail OrderOther Services and Supplies Durable Medical Equipment & Prosthetic Devices Home Health Care10% after deductible40% after deductibleNo charge after deductibleNo charge after deductible10% after deductible40% after deductible Physical 20 copayNot covered Occupational 20 copayNot covered Speech 20 copayNot covered Skilled Nursing or Extended Care Facility Hospice CareOutpatient Rehabilitative Therapy ServicesThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.Washington Unified School District, West Sacramento11
Medical (continued)Toolsmyuhc.comCaliforniaChoosing a network physicianjust got simpler.Finding a doctor, specialist or facility couldn’t be easier.Just follow the steps below.1Go to myuhc.com . Select Find a Doctor. Select Medical Directory. Select All UnitedHealthcare Plans.23Select your plan type.UnitedHealthcare SignatureValue or HMO plans.UnitedHealthcare Navigate , Select Plusor Core plans. Select SignatureValue Plans. Select Medical Directory. Select the state in which you live. Select your network from the list provided. Enter your ZIP code or city and state. Select Navigate, Select Plus or Core. Enter your ZIP code or city and state. Search by physician name, medical group, clinic,facility, specialty or condition.Search by people or place.To search by people:To search by place:Select between Primary Care, Specialty Careor Medical Groups.*Select between Hospitals, Specialty Centers,Labs and Imaging* or Clinics.* For Primary Care: Select a type of Primary Provider(Family Doctor, Generalist, Internist, etc.). For Specialty Care: Select a type of Specialist(Acupuncturist, Allergist/Immunologist, etc.). For Medical Groups: Select your Medical Group Name. For Hospitals: Select the Location. For Specialty Centers: Select which type ofSpecialty Center (Birth Centers, Blood Banks,Community Clinics, etc.). For Clinics: Select between Convenience Clinicor Urgent Care Clinic. For Labs and Imaging: Select betweenImaging Centers or Lab Locations.Formal HMO product names.Signature: UnitedHealthcare SignatureValue Advantage: UnitedHealthcare SignatureValue AdvantageAlliance: UnitedHealthcare SignatureValue AllianceFocus: UnitedHealthcare SignatureValue FocusHarmony: UnitedHealthcare SignatureValue HarmonyCONTINUED* For Core/Select Plus/Navigate only.12Washington Unified School District, West Sacramento
Medical (continued)Note: Members will need to select a primary care physician (PCP) at the time of enrollment. If you do not select a PCP duringenrollment, a PCP in your geographic area who is accepting new patients will be assigned. Once a PCP has been selected, click on the Enrollment Information tab.Under the Enrollment Information tab,you will find the Provider ID number.Please indicate the primary carephysician’s name and 10-digit ID numberon your enrollment form.Important: Some PCPs may havemore than one ID number based ontheir medical group, location or hospitalaffiliation. Please be sure you select the IDnumber that aligns with the medical group,location and hospital of your choice.Health plan coverage provided by or through UnitedHealthcare Insurance Company, UHC of California and UnitedHealthcare Benefits Plan ofCalifornia. Administrative services provided by United Healthcare Services, Inc., OptumRx or OptumHealth Care Solutions, Inc. Behavioralhealth products are provided by U.S. Behavioral Health Plan, California m/UnitedHealthcareTwitter.com/UHCEI2082148.0 2/20 2020 United HealthCare Services, Inc. 20-79084-BWashington Unified School District, West SacramentoYouTube.com/UnitedHealthcare13
Medical (continued)Post 65 Retirees Only (Certificated)Plan BenefitsLifetime MaximumMaximum Out of PocketKaiser Permanente Senior Advantage HMO 5Member ResponsibilityUnlimited 1,500 Individual/ 3,000 FamilyPreventive Services Routine PhysicalNo chargePhysician/Diagnostic Services Office Visits Lab & X-ray & Diagnostic Test 5 copayNo chargeHospital Services Semi-Private Room & BoardNo charge Outpatient Surgery 5 copay Emergency Rooms (waived if admitted with 24 hours) 20 copay Urgent Care 5 copayOther Services AmbulanceNo charge Durable Medical EquipmentNo chargeVision Services 175 allowance for each eyewear purchased at a Plan Medical OfficePrescription Drugs Generic (Up to a 100-day supply) 5 copay Brand (Up to a 100-day supply) 10 copayThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.14Washington Unified School District, West Sacramento
Medical (continued)Post 65 Retirees Only (Certificated)Plan BenefitsLifetime MaximumMaximum Out of Pocket (individual only)HealthNet Seniority PlusMember ResponsibilityUnlimited 3,400Preventive Services Routine PhysicalNo charge ImmunizationsNo chargePhysician/Diagnostic Services Office Visits Lab & X-ray & Diagnostic Test 5 copayNo chargeHospital Services Semi-Private Room & BoardNo charge Outpatient SurgeryNo charge Emergency Room (waived if admitted) 20 copay Urgent Care (waived if admitted) 20 copayOther Services Ambulance Vision Services (Medicare only) Durable Medical EquipmentNo charge 5 copay Exam/ No charge Lenses/No charge for Frames after each cataract surgeryNo chargePrescription Drugs Retail Prescription (Up to a 30-day Supply) 7 copay Retail Prescription (Up to a 90-day Supply) 21 copay Mail Order (Up to a 90-day Supply) 14 copayWhen Medicare Part D out-of-pocket costsexceed 4,550 you pay higher of: 3.40 Generic / 8.50 all other drugs or 5% coinsurance copayThe information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, orqualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail.Washington Unified School District, West Sacramento15
2022 CalPERS – HMO & PPO Basic Plans (Classified Only)Region 1The following pages include all of the plans offered by CalPERS. Please note that not all plans are available to Washington USD.Here is a list of the plans offered to the district:HMO Plans Anthem Blue Cross Del Norte Anthem Blue Cross Select Anthem Blue Cross Traditional Blue Shield Access Blue Shield Access EPO Blue Shield Trio Health Net SmartCare Kaiser Permanente United Healthcare SignatureValue Alliance Western Health AdvantagePPO Plans16 PERS Gold PPO PERS Platinum PPOWashington Unified School District, West Sacramento
2022 CalPERS – EPO & HMO Basic Plans (Classified Only)For more details about the benefits provided by a specific plan, refer to that plan’s Evidence of Coverage (EOC) booklet.BenefitsAnthemBlue CrossBlue ShieldDel Norte County EPOSelect HMOTraditional HMOAccess HMO &Access EPOTrio HMOSalud y Más HMOSmartCare HMOHealth hcareSignatureValueAlliance HMOHarmony HMOWesternHealthAdvantageHMOCalendar Year Deductible IndividualN/AN/AN/AN/AN/AN/AN/A FamilyN/AN/AN/AN/AN/AN/AN/AMaximum Calendar Year Copay or Coinsurance (excluding pharmacy) Individual 1,500 (copay) 1,500 (copay) 1,500 (copay) 1,500 (copay) 1,500 (copay) 1,500 (copay) 1,500 (copay) Family 3,000 (copay) 3,000 (copay) 3,000 (copay) 3,
a Health Net HMO medical group or Kaiser Facility.) You have the choice to select one plan from the following: Kaiser Permanente HMO Senior Advantage (California Only) Health Net HMO Seniority Plus (California Only) Medical Visit Kaiser Permanente: www.kp.org Visit Western Health
