Medical Plan Summary of Benefits Chart
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC.
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC. EOCs are available for download at sfhss.org.
| medical plans | ||||||
|---|---|---|---|---|---|---|
KAISER PERMANENTE | BLUE SHIELD OF CALIFORNIA | HEALTH NET: Plan terminates February 2027 | ||||
TRADITIONAL HMO | TRIO HMO | ACCESS+ HMO | PPO | CANOPYCARE HMO | ||
Choice of Physician | PCP assignment required. | PCP assignment required. | PCP assignment required. | You may use any licensed provider. You receive a higher level of benefit and pay lower out-of-pocket costs when choosing in-network providers. | PCP assignment required. | |
| Deductible | No deductible | No deductible | No deductible | IN-NETWORK AND OUT-OF-AREA | OUT-OF-NETWORK | No deductible |
$250 employee only $500 +1 Dependent $750 +2 or more Dependents | $500 employee only $1,000 +1 Dependent $1,500 +2 or more Dependents | |||||
| Out-of-Pocket Maximum | $1,500 per individual $3,000 per family | $2,000 per individual $4,000 per family | $2,000 per individual $4,000 per family | $3,750 per individual $7,500 per family | $7,500 per individual | $2,000 per individual $4,000 per family |
| General Care and Urgent Care | ||||||
Annual Physical; Well Woman Exam | No charge | No charge | No charge | 100% covered no deductible | 50% covered after deductible | No charge |
| Doctor Office Visit | $20 co-pay | $25 co-pay | $25 co-pay | 85% covered after deductible | 50% covered after deductible | $25 co-pay |
| Urgent Care Visit | $20 co-pay | $25 co-pay | $25 co-pay | 85% covered after deductible | 50% covered after deductible | $25 co-pay |
| Family Planning | No charge | No charge | No charge | 100% covered no deductible | 50% covered after deductible | No charge |
| Immunizations | No charge | No charge | No charge | 100% covered no deductible | 100% covered no deductible | No charge |
| Lab and X-ray | No charge | No charge | No charge | 85% covered after deductible & prior notification | 50% covered after deductible & prior notification | No charge |
| Doctor’s Hospital Visit | No charge | No charge | No charge | 85% covered after deductible | 50% covered after deductible | No charge |
| Prescription Drugs | ||||||
| Pharmacy: Generic | $5 co-pay 30-day supply | $10 co-pay 30-day supply | $10 co-pay 30-day supply | $10 co-pay 30-day supply | $10 co-pay plus 50% Coinsurance; 30-day supply | $10 co-pay 30-day supply |
Pharmacy: Brand-Name | $15 co-pay 30-day supply | $25 co-pay 30-day supply | $25 co-pay 30-day supply | $25 co-pay 30-day supply | $25 co-pay plus 50% Coinsurance; 30-day supply | $25 co-pay 30-day supply |
Pharmacy: Non-Formulary | Only if authorized by a Kaiser Physician | $50 co-pay 30-day supply | $50 co-pay 30-day supply | $50 co-pay 30-day supply | $50 co-pay, plus 50% Coinsurance; 30-day supply | $50 co-pay 30-day supply |
| Mail Order: Generic | $10 co-pay 100-day supply | $20 co-pay 90-day supply | $20 co-pay 90-day supply | $20 co-pay 90-day supply | Not covered | $20 co-pay 90-day supply |
Mail Order: Brand-Name | $30 co-pay 100-day supply | $50 co-pay 90-day supply | $50 co-pay 90-day supply | $50 co-pay 90-day supply | Not covered | $50 co-pay 90-day supply |
Mail Order: Non-Formulary | Only if authorized by a Kaiser Physician | $100 co-pay 90-day supply | $100 co-pay 90-day supply | $100 co-pay 90-day supply | Not covered | $100 co-pay 90-day supply |
| Specialty | 20% up to $100 co-pay; 30-day supply | 20% up to $100 co-pay; 30-day supply | 20% up to $100 co-pay; 30-day supply | $50 co-pay 30-day supply | $50 co-pay, plus 50% Coinsurance; 30-day supply | 20% up to $100 co-pay; 30-day supply |
| Hospital Outpatient and Inpatient | ||||||
Hospital Outpatient | $35 co-pay | $100 co-pay per surgery | $100 co-pay per surgery | 85% covered after deductible | 50% covered after deductible | $100 co-pay per surgery |
Hospital Inpatient | $100 co-pay per admission | $200 co-pay per admission | $200 co-pay per admission | 85% covered after deductible; may require prior notification | 50% covered after deductible; may require prior notification | $200 co-pay per admission |
Hospital Emergency Room | $100 co-pay waived if hospitalized | $100 co-pay waived if hospitalized | $100 co-pay waived if hospitalized | 85% covered after deductible if non-emergency, 50% after deductible | 85% covered after deductible if non-emergency, 50% after deductible | $100 co-pay waived if hospitalized |
Skilled Nursing Facility | No charge 100 days per benefit period | No charge 100 days per plan year | No charge 100 days per plan year | 85% covered after deductible; 120 days per plan year; limits apply | 50% covered after deductible; 120 days per plan year; limits apply | No charge 100 days per plan year |
| Hospice | No charge when medically necessary | No charge authorization required | No charge authorization required | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | No charge authorization required |
| Maternity and Infertility | ||||||
Hospital or Birthing Center | $100 co-pay per admission | $200 co-pay per admission | $200 co-pay per admission | 85% covered after deductible; may require prior notification | 50% covered after deductible; may require prior notification | $200 co-pay per admission |
Pre-/Post-Partum Care | No charge | No charge | No charge | 85% covered after deductible | 50% covered after deductible | No charge |
| Well Child Care | No charge must enroll newborn within 30 days of birth; see EOC | No charge must enroll newborn within 30 days of birth; see EOC | No charge must enroll newborn within 30 days of birth; see EOC | 100% covered no deductible | 100% covered no deductible | No charge must enroll newborn within 30 days of birth; see EOC |
| Fertility Services | Co-pays apply; authorization required | Co-pays apply; authorization required | Co-pays apply; authorization required | 85% covered after deductible; limitations apply; prior notification | 50% covered after deductible; limitations apply; prior notification | Co-pays apply; authorization required |
| Mental Health and Substance Abuse Services | ||||||
Outpatient Treatment | $10 co-pay group $20 co-pay individual | $25 co-pay non-severe and severe | $25 co-pay non-severe and severe | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | $25 co-pay non-severe and severe |
| Inpatient Facility | $100 co-pay per admission | $200 co-pay per admission | $200 co-pay per admission | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | $200 co-pay per admission |
| Other | ||||||
| Hearing Aids | Up to $2,500 per ear, every 36 months; no evaluation charge | Up to $2,500 per ear, every 36 months; no charge for evaluation | Up to $2,500 per ear, every 36 months; no charge for evaluation | 85% covered after deductible; up to $2,500 per ear, every 36 months | 50% covered after deductible; up to $2,500 per ear, every 36 months | Up to $5,000, combined for both ears, every 36 months; no charge for evaluation |
Medical Equipment, Prosthetics and Orthotics | No charge as authorized by PCP | No charge as authorized by PCP | No charge as authorized by PCP | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | No charge as authorized by PCP |
Medical Equipment, Prosthetics and Orthotics | No charge as authorized by PCP | No charge as authorized by PCP | No charge as authorized by PCP | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | No charge as authorized by PCP |
Physical and Occupational Therapy | $20 co-pay authorization required | $25 co-pay | $25 co-pay | 85% covered after deductible; limitations may apply, see EOC | 50% covered after deductible; limitations may apply, see EOC | $25 co-pay |
Acupuncture/ Chiropractic | $15 co-pay up to a combined total of 30 chiropractic and acupuncture visits/ year; ASH network | $15 co-pay 30 visits max for Acupuncture per plan year; ASH network $15 co-pay 30 visits max for Chiropractic per plan year; ASH network | $15 co-pay 30 visits max for Acupuncture per plan year; ASH network $15 co-pay 30 visits max for Chiropractic per plan year; ASH network | 50% covered after deductible; $1,000 max per plan year | 50% covered after deductible; $1,000 max per plan year | $15 co-pay 30 visits max for Acupuncture per plan year; ASH network $15 co-pay 30 visits max for Chiropractic per plan year; ASH network |
| Gender Dysphoria | Co-pays apply; authorization required | Co-pays apply; authorization required | Co-pays apply; authorization required | 85% covered after deductible; prior notification | 50% covered after deductible; prior notification | Co-pays apply; authorization required |