2022 PPO Benefit Highlights


Anthem PPO


In-Network
Out-of-Network

Calendar Year Deductible
$750/person; $1,500/family
$1,250/person; $2,500/family

Calendar Year
Out-of-Pocket Limit
$2,000/person; $4,000/family, in-network and out-of-network combined

Routine Office Visits
(including pediatric visits)
Plan pays 100% after $30 copay/visit with no deductible; 90% after deductible for any procedures as part of visit Plan pays 100% for Well-Baby & Well-Child Care
Plan pays 70% of allowed charges2 after deductible

Online Doctor Visits
Plan pays 100% after $30 copay
N/A

Preventive Care1
Plan pays 100%, no deductible
Plan pays 70% of allowed charges2 after deductible

Maternity Care
(Office Visits) & Pregnancy
Prenatal and postnatal office visits for services mandated by the Affordable Care Act (ACA):
Plan pays 100%; no copay, no deductible.
Other prenatal/postnatal office visits: Plan pays 100% after $30 copay/visit with no deductible.
Other services: Plan pays 90% after deductible
Plan pays 70% of allowed charges2 after deductible

Inpatient Hospitalization


Plan pays 90% after deductible; prior authorization needed3
Plan pays 70% of allowed charges2 after deductible, up to $1,500 per day maximum allowed charges. You are responsible for all charges in excess of $1,500 per day. Prior authorization is needed.3

Outpatient Surgery


Plan pays 90% after deductible
Plan pays 70% of allowed charges2 after deductible, up to $350 per day maximum allowed charges. You are responsible for all charges in excess of $350 per day.

Diagnostic Lab Work and X-rays
Plan pays 90% after deductible
Plan pays 70% of allowed charges2 after deductible

Emergency Room Care for True Emergencies (severe chest pains, breathing difficulties, severe bleeding, poisoning, etc.)
Plan pays 90% after $100 copay/visit; copay waived if admitted and regular hospitalization benefits apply
Plan pays 90% after $100 copay/visit; copay waived if admitted and regular hospitalization benefits apply

Hearing Aid Benefit
Plan pays 80% after deductible for one hearing aid per ear every 24 months
Plan pays 80% of allowed charges2 after deductible for one hearing aid per ear every 24 months
1 Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and federal regulations. Go to the website for your health plan or call your health plan if you have questions about coverage.
2 When members use non-preferred providers, they must pay the applicable copay and coinsurance plus any amount that exceeds Anthem Blue Cross’s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket limit.
3 You or your doctor must contact Anthem for preauthorization and approval at a non-participating provider before a hospital stay or you will be responsible for a penalty of $250.
 

2022 HMO Benefit Highlights
Kaiser Permanente HMO
Anthem Narrow Network
(Select HMO)
Anthem Full Network
(CACare HMO)
Anthem Vivity HMO
(LA & Orange Counties)

Calendar Year Deductible
$0
$0

Calendar Year
Out-of-Pocket Limit
$1,500/person; $3,000/family
$500/person; $1,500/family

Routine Office Visits
(including pediatric visits)
Plan pays 100% after $15 copay/visit2
Plan pays 100% after $15 copay/visit2

Virtual Visits
Plan pays 100%
Plan pays 100% after $15 copay/visit2

Preventive Care1
Plan pays 100%
Plan pays 100%

Maternity Care
(Office Visits) & Pregnancy
Plan pays 100%
Plan pays 100%

Inpatient Hospitalization
Plan pays 100%
Plan pays 100%

Outpatient Surgery
Plan pays 100% after $15 copay/procedure
Plan pays 100%

Diagnostic Lab Work and X-rays
Plan pays 100% at a Kaiser facility
Plan pays 100%

Emergency Room Care for True Emergencies (severe chest pains, breathing difficulties, etc.)
Plan pays 100% after $100 copay/ visit; copay waived if admitted
Plan pays 100% after $100 copay/visit; copay waived if admitted

Hearing Aid Benefit
Plan pays up to $2,000 for one device per ear every 36 months; covers all visits for fitting, counseling, adjustment, cleaning, and inspection
Plan pays for one hearing aid per ear every 24 months
1 Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and federal regulations. Go to the website for your health plan or call your health plan if you have questions about coverage.
2 Copay varies by office visit type. See the Evidence of Coverage for more details.

2020 Employee/Employer Costs for "LAwell Plan" Health Coverage

Your 2020 Medical Plan Coverage Costs Per Pay Period (Every Two Weeks)
Coverage Level City Pays… Full-time
Employee Pays…		 City Pays… Half-time
Employee Pays…		 Total Cost of Coverage
Bi-Weekly
(per Pay Period)
Kaiser Permanent HMO
Employee Only $310.06 $0.00 $310.06 $0.00 $310.06
Employee & Spouse/DP $682.13 $0.00 $310.06 $372.07 $682.13
Employee + Child(ren) $620.12 $0.00 $310.06 $310.06 $620.12
Employee + Family $806.16 $0.00 $310.06 $496.10 $806.16
Anthem Narrow Network HMO (Select)
Employee Only $335.83 $0.00 $310.06 $25.77 $335.83
Employee & Spouse/DP $738.86 $0.00 $310.06 $428.80 $738.86
Employee + Child(ren) $638.11 $0.00 $310.06 $328.05 $638.11
Employee + Family $806.16 $67.05 $310.06 $563.15 $873.21
Anthem Full Network HMO (CACare)
Employee Only $335.83 $138.40 $310.06 $164.17 $474.23
Employee + Spouse/DP $738.86 $304.43 $310.06 $733.23 $1,043.29
Employee + Child(ren) $638.11 $262.91 $310.06 $590.96 $901.02
Employee + Family $806.16 $426.84 $310.06 $922.94 $1,233.00
Anthem Vivity HMO (LA & Orange Counties)
Employee Only $281.92 $0.00 $281.92 $0.00 $281.92
Employee + Spouse/DP $620.24 $0.00 $310.06 $310.18 $620.24
Employee + Child(ren) $535.65 $0.00 $310.06 $225.59 $535.65
Employee + Family $733.00 $0.00 $310.06 $422.94 $733.00
Anthem PPO
Employee Only $540.06 $0.00 $310.06 $230.00 $540.06
Employee + Spouse/DP $806.16 $381.99 $310.06 $878.09 $1,188.15
Employee + Child(ren) $806.16 $219.95 $310.06 $716.05 $1,026.11
Employee + Family* $806.16 $598.01 $310.06 $1,094.11 $1,404.17

2020 Employer/Employee Costs for "LAwell Pay Plan" Health Coverage

Your 2020 Medical Plan Coverage Costs Per Pay Period (Every Two Weeks)
Coverage Level City Pays… Full-time
Employee Pays…		 City Pays… Half-time
Employee Pays...		 Total Cost of Coverage
Bi-Weekly
(per Pay Period)
Kaiser Permanente HMO
Employee Only $279.06 $31.00 $279.06 $31.00 $310.06
Employee & Spouse/DP $613.92 $68.21 $279.06 $403.07 $682.13
Employee + Child(ren) $558.11 $62.01 $279.06 $341.06 $620.12
Employee + Family $725.55 $80.61 $279.06 $527.10 $806.16
Anthem Narrow Network HMO (Select)
Employee Only $302.25 $33.58 $279.06 $56.77 $335.83
Employee + Spouse/DP $664.98 $73.88 $279.06 $459.80 $738.86
Employee + Child(ren) $574.30 $63.81 $279.06 $359.05 $638.11
Employee + Family $725.55 $147.66 $279.06 $594.15 $873.21
Anthem Full Network HMO (CACare)
Employee Only $302.25 $171.98 $279.06 $195.17 $474.23
Employee + Spouse/DP $664.98 $378.31 $279.06 $764.23 $1,043.29
Employee + Child(ren) $574.30 $326.72 $279.06 $621.96 $901.02
Employee + Family $725.55 $507.45 $279.06 $953.94 $1,233.00
Anthem Vivity HMO (LA & Orange Counties)
Employee Only $253.73 $28.19 $253.73 $28.19 $281.92
Employee + Spouse/DP $558.22 $62.02 $279.06 $341.18 $620.24
Employee + Child(ren) $482.09 $53.56 $279.06 $256.59 $535.65
Employee + Family $659.70 $73.30 $279.06 $453.94 $733.00
Anthem PPO
Employee Only $486.06 $54.00 $279.06 $261.00 $540.06
Employee + Spouse/DP $725.55 $462.60 $279.06 $909.09 $1,188.15
Employee + Child(ren) $725.55 $300.56 $279.06 $747.05 $1,026.11
Employee + Family $725.55 $678.62 $279.06 $1,125.11 $1,404.17
Domestic partnerships are not recognized under federal tax law, and enrollment of domestic partner dependents may result in different taxable income treatment. See page 46 for more information.