Healthcare Compare 2020 Plans

The information contained in this comparison tool is not the official statement of benefits. Before making your final enrollment decision, always refer to the individual FEHB brochure which is the official statement of benefits. The amounts shown below indicate what you will pay for each class of service. When you see a plus sign (+), it means you must pay the stated coinsurance AND any difference between your Plan’s allowance and the provider’s billed amount. When a “yes” appears indicating that there is coverage for a specific service, you must check the plan brochure for your cost share. NOTE: HDHP plans require that the combined medical and pharmacy deductible be met before traditional coverage begins.

Self

Self Plus One

Self & Family

	Aetna Open Access (High)		Health Net of California (High)		Kaiser Foundation Health Plan of California (High)	Panama Canal Area Benefit Plan (High)
Plan Links
	Website Brochure Summary of Benefits Provider Directory RX Pricing Tool		Website Brochure Summary of Benefits Provider Directory RX Pricing Tool		Website Brochure Summary of Benefits Provider Directory RX Pricing Tool	Website Brochure Summary of Benefits Provider Directory RX Pricing Tool
General Information
State	California		California		California	California
Enrollment Code - Self	2X1		LP1		621	431
Enrollment Code - Self & Family	2X2		LP2		622	432
Enrollment Code - Self Plus One	2X3		LP3		623	433
Carrier Code	2X		LP		62	43
Plan Type	HMO		HMO		HMO	FFS
Telephone Number	877-459-6604		800-522-0088		800-464-4000	800-424-8196
Costs & Network
Biweekly Premium	$170.63 $431.28 $407.64		$248.09 $560.37 $614.79		$103.65 $280.34 $237.99	$72.52 $144.75 $151.38
	In-Network 1	Out-of-Network	In-Network 1	Out-of-Network	In-Network 1	In-Network 1	Out-of-Network
Annual Deductible Annual Deductible: The amount you may have to pay for covered health care services before the plan begins to pay. Some plans have both an overall deductible for all or most covered items/services, but some also have separate deductibles for specific types of services (e.g. prescription services).	None None None	None None None	None None None	None None None	None None None	None None None	None None None
Type of Account	None	None	None	None	None	None	None
Medical Account Contribution The amount of funds available to you for paying your out-of-pocket qualified medical expenses through a premium pass-through contribution or a virtual account.	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Net Deductible A net deductible is the sum of your deductible minus any medical account fund.	None None None	None None None	None None None	None None None	None None None	None None None	None None None
Annual Out-of-Pocket Maximum Annual Maximum Out of Pocket: Yearly amount the Federal government sets as the most each individual or family is required to pay in cost sharing (e.g. copayments, deductibles and coinsurance) during the plan year for covered, in-network services. This amount may be higher than the out of pocket limits the plan sets.	$5,000.00 $10,000.00 $10,000.00	None None None	$1,500.00 $3,000.00 $4,500.00	None None None	$2,000.00 $4,000.00 $4,000.00	None None None	$2,500.00 $2,500.00 $2,500.00
Medicare Coordination
Services & Benefits
	In-Network 1	Out-of-Network	In-Network 1	Out-of-Network	In-Network 1	In-Network 1	Out-of-Network
Member Cost with Medicare A & B Primary This is your cost share.
Deductible Waiver This field will indicate either the amount of your annual deductible or that the deductible has been waived (forgiven) when Medicare A and B is the primary coverage.	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Out-of-Pocket Maximum This is the most you have to pay annually in cost-sharing (deductibles, copayments and coinsurance) for covered, in-network services in your FEHB plan when Medicare A and B is your primary coverage.	$5000	N/A	$1500 $3000 $4500	N/A	$2000	$5000	$5000 $2500
Primary Care Office Visit with Medicare A & B Primary This is the amount you pay for a primary care visit. When you have Medicare A and B, some plans will waive the copay.	$20	N/A	$20	N/A	$10	$5	Coinsurance Waived Copayment Waived
Specialty Office Visit This is the amount you pay for a Specialty care visit. When you have Medicare A and B, some plans will waive the copay.	$35	N/A	$30	N/A	$10	$5	Coinsurance Waived Copayment Waived
Inpatient Hospital This is the amount you pay for an inpatient hospital stay. When you have Medicare A and B, some plans waive this amount.	$250 Per Day Up To $1000 Per Admission	N/A	$150 Per Day Up To $750 Per Admission	N/A	$250	$25	Coinsurance Waived Copayment Waived
Outpatient Hospital This is the amount you pay for an outpatient hospital visit when you have Medicare Parts A & B as your primary coverage.What is the amount a member with Medicare A and B pays for an outpatient hospital visit?	$175	N/A	$200	N/A	$50	$25	Coinsurance Waived Copayment Waived
Part B Premium Reimbursement If a plan reimburses you for your Part B premiums, this displays the maximum amount that you will be reimbursed. A ‘No” means that the premium will not be reimbursed.	No	N/A	N/A	N/A	$1500 Max	N/A	N/A
Primary/Specialty Care This is your cost share.
Preventive Care What is the member cost share for Preventive Care, as defined by the U.S. Preventive Services Task Force with a rating of A or B?	You pay nothing	N/A	You pay nothing	N/A	Member Pays Nothing	You pay nothing	Member Pays Nothing
Primary Care Office Visit The amount you pay for a visit to a primary care practitioner (typically an M.D. or D.O., but can include other licensed providers).	$20	N/A	$20	N/A	$15	$5	50% +
Specialist Office Visit The amount you pay for a visit to a provider focusing on a specific area of medicine. Some plans require a referral from your primary care provider for you to see a specialist. You must get a referral, if required, or your plan may not pay for the services.	$35	N/A	$30	N/A	$25	$5	50% +
Plan Requires Referral to See Certain Specialists A written order from your primary care provider for you to see a specialist or get certain health care services. Some plans may require you need to get a referral before you can get health care services from anyone other than your primary care provider. In those plans, if you don’t get a referral first, the plan may not pay for the services	No	N/A	Yes	N/A	Yes	Yes	No
Emergency & Urgent Care This is your cost share.
Emergency Care What is the member cost share for Emergency Care?	$125	$125	$100	$100	$100	$5	50% +
Urgent Care What is the member cost share for Urgent Care?	$50	N/A	$20	$20	$15	Member Pays Nothing	50% +
Out-of-Pocket Waived Is a member's Out-of-Pocket cost waived when the member is admitted to the hospital following ER treatment? Select "NA" if a member pays nothing for any medical emergency.	Yes	N/A	Yes	Yes	Yes	No	No
Surgery & Hospital Charges This is your cost share.
Doctor Costs Inpatient Surgery The amount you will pay for a doctor to perform inpatient surgery.	You pay nothing	N/A	You pay nothing	N/A	Member Pays Nothing	You pay nothing	50% +
Hospital Inpatient Cost Per Admission This is the amount you pay before the Plan pays benefits when you are admitted as an inpatient to a hospital.	$250/day up to $1000/admit	N/A	$150/day up to $750/admit	N/A	$250	$25	$100 +
Room & Board Charges This is the amount you pay for covered Room & Board charges while an inpatient in a hospital.	You pay nothing	N/A	You pay nothing	N/A	Member Pays Nothing	You pay nothing	50% +
Other Inpatient Costs This is the amount you pay for other costs associated with inpatient surgery.	You pay nothing	N/A	You pay nothing	N/A	Member Pays Nothing	You pay nothing	50% +
Doctor Costs Outpatient Surgery This is the amount you pay for a doctor to perform surgery in an outpatient hospital setting or ambulatory surgery center.	You pay nothing	N/A	You pay nothing	N/A	$50	You pay nothing	50% +
Other Outpatients Costs This is the amount you pay for other outpatient care at a hospital (not surgery or emergency room services).	$175	N/A	$200	N/A	Member Pays Nothing	You pay nothing	50% +
Lab, X-Ray & Other Diagnostic Tests This is your cost share.
Simple Diagnostic Tests/Procedures What is the member cost share for Simple Diagnostic Tests/Procedures (e.g., blood tests, urinalysis, ultrasounds)?	$20 min $35 max	N/A	You pay nothing	N/A	Member Pays Nothing	You pay nothing	50% +
Complex Diagnostic Tests/Procedures What is the member cost share for Complex Diagnostic Tests/Procedures (e.g., CT scans, MRIs, PET scans, sleep labs)?	$20 min $75 max	N/A	$250	N/A	Member Pays Nothing	You pay nothing	50% +
Enhanced Lab Network What is the member cost share for Enhanced lab Network?	$20 min $75 max	N/A	N/A	N/A	N/A	You pay nothing	50% +
Prescription Drugs (Plans may not have drugs on the same tier. For more information on a specific drug, refer to each plan's RX Pricing tool below.) This is your cost share.
Separate Annual Out-of-Pocket Maximum	None	None	2900	None	None	5000	5000
Separate Annual Deductible	None None None	None None None	None None None	None None None	None None None	None None None	None None None
Retail Generic The amount you will pay to fill a prescription for retail generic drugs.	Tier 1: $10 Tier 3: $100	N/A	Tier 1: $10	N/A	$10	20%	20%
Retail Brand The amount you will pay to fill a prescription for retail brand name drugs.	Tier 1: $35 Tier 3: $100	N/A	Tier 2: $35 Tier 3: $60	N/A	$40	20%	20%
Specialty Your cost share for specialty prescription drugs. Specialty prescription drugs are high cost, complex drugs placed on a specialty tier of the formulary and/or dispensed from a designated specialty pharmacy.	Tier 4: 50% $350 max Tier 5: 50% $700 max	N/A	Tier 4: 20% $200 max	N/A	$100	20%	20%
Mail Service Pharmacy Benefit This is the amount you pay for a mail order prescription. These are medications sent via mail for maintenance prescriptions, typically greater than a 30-day supply.	Yes	N/A	Yes	N/A	Yes	No	No
Medication Pricing Tool	Go To RX Pricing Tool		Go To RX Pricing Tool		Go To RX Pricing Tool	Go To RX Pricing Tool
Treatment Therapies This is your cost share.
Applied Behavioral Analysis (ABA) This is the amount you pay for Applied Behavior Analysis (ABA) coverage.	$35	N/A	You pay nothing	N/A	$15/day	No	No
Chiropractic Your cost share for chiropractic care.	$35	N/A	$10	N/A	$15	$10	50% +
Occupational Therapy Your cost share for occupational therapy.	$35	N/A	You pay nothing	N/A	$15	You pay nothing	50% +
Physical Therapy Your cost share for physical therapy.	$35	N/A	You pay nothing	N/A	$15	Member Pays Nothing	50% +
Speech Therapy Your cost share for speech therapy.	$35	N/A	You pay nothing	N/A	$15	You pay nothing	50% +
Dental This is your cost share.
Preventive Dental for Adults Does the plan cover Preventive Dental for Adults?	Yes	Yes	No	N/A	No	Yes	Yes
Preventive for Children Does the plan cover Preventive Dental for Children?	Yes	Yes	No	N/A	No	Yes	Yes
Minor Restorative for Adults Does the plan cover Minor Restorative for Adults (e.g., fillings, local anesthesia)?	Yes	Yes	No	N/A	No	No	No
Minor Restorative for Children Does the plan cover Minor Restorative for Children (e.g., fillings, local anesthesia)?	Yes	Yes	No	N/A	No	No	No
Major Restorative for Adults Does the plan cover Major Restorative for Adults (e.g., endodontics, crowns, prosthodontics)?	No	No	No	N/A	No	No	No
Major Restorative for Children Does the plan cover Major Restorative for Children (e.g., endodontics, crowns, prosthodontics)?	No	No	No	N/A	No	No	No
Orthodontic Does the plan cover Orthodontics?	No	No	No	N/A	No	No	No
Vision This is your cost share.
Routine Eye Exams Does the plan cover Routine Eye Exams?	Yes	N/A	Yes	N/A	Yes	No	No
Eye Exams for Medical Condition or Non-Surgical Treatment Does the plan cover Eye Exams for Medical Condition or Non-Surgical Treatment?	Yes	N/A	Yes	N/A	Yes	No	No
Eyeglass Frames & Lenses Does the plan cover Eyeglass Frames and Lenses?	Yes	Yes	No	N/A	No	No	No
Contacts Does the plan cover Contacts?	Yes	Yes	No	N/A	No	No	No
Alternative Care This is your cost share.
Alternative Care Your plan may cover some type of alternative care such as: acupuncture, massage therapy, hypnotherapy, holistic medicine, Yoga, herbal treatments, or naturopathic services. Please consult the plan brochure for more information.	Yes	N/A	Yes	N/A	Yes	Yes	Yes
Quality The measures below show how well a plan provides or coordinates care for its enrollees.
Key: Outstanding Excellent Good Fair Poor NA is displayed if a plan did not report or is unable to report a result in this coverage area.
Breast Cancer Screening Do women who need screening mammograms get them?
Avoidance of Antibiotics in Adults with Acute Bronchitis Appropriate use of antibiotics for accute bronchitis
Controlling High Blood Pressure People with high blood pressure receive effective treatment.
Timeliness of Prenatal Care Pregnant women receive care in the first trimester.
Use of Imaging Studies for Low Back Pain Appropriate treatment of lower back pain.
Asthma Medication Ratio Appropriate ratio of controller medications to total asthma medications
Plan All Cause Readmissions Reduced likelihood of readmission following inpatient hospital stay.
Customer Service The measures below show what people think about their plan.
Overall Plan Satisfaction How pleased are customers with the plan overall?
Claims Processing How quickly do customers say the plan handles claims?
Customer Service How satisfied are customers with the plan's customer service?
Getting Needed Care Members report getting the care they need.
Coordination of Care Members say that their doctors know about care from other providers