Network+ - Benefits Comparison

BENEFITS COMPARISON

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Stanislaus County HMO Benefit Comparison 2009

	HPSJ	KAISER	PACIFICARE	PACIFICARE
	NETWORK+	PERMANENTE	HMO	POINT OF SERVICE
				See Brochure For Tier Two & Tier Three

INPATIENT:				Tier One-HMO
*Room/Supplies	No Charge	No Charge	No Charge	No Charge
*Surgery Services	No Charge	No Charge	No Charge	No Charge
*Hospice Care	No Charge	No Charge	No Charge	No Charge
*Skilled Nursing	No Charge x 100 days	No Charge x 100 days	No Charge x 100 days	No Charge x 100 days
*Professional Services	No Charge	No Charge	No Charge	No Charge

OUTPATIENT:
*Surgery	$50	$20	$50	No Charge
*Second opinion	$20	$20	$20	$20
*MD ofc or home visit	$20	$20/MD office	$20	$20 MD office
		N/C Nurse Home Visits
*Laboratory	No Charge	No Charge	No Charge	No Charge
*X-Ray	No Charge	No Charge	No Charge	No Charge
*Physical/occupational/	$20	$20/60 days	$20/60 days	$20
speech therapy		consecutive days	consecutive days
*Home health	No Charge	No Charge	No Charge	No Charge

PREVENTION ADULT:
*Screening,	$20	$20	$20	$20
immunizations and	Immunization	Immunization
counseling (2)	No Charge	No Charge
*Prenatal	$20	$20	$20	$20

PREVENTION: CHILD
(Newborn-17):
*Screening,	$20	$20	$20	$20
immunizations and	Immunization	Immunization
counseling(2)	No Charge	No Charge
*Well baby care (1)	No Charge	$20	No Charge	$20

FAMILY PLANNING
*Infertility	Not Covered	Not Covered	Not Covered	50% (1)
*Contraceptive	$10 Generic/$20 Brand/30 days	$10 Generic/$20 Brand/100 days	$10 Generic/$20 Brand/28 days	$10 Generic/$20 Brand

OTHER
*Prescriptions	$10 Generic/$20 Brand/30 days(1)	$10 Generic/$20 Brand/100 days(1)	$10 Generic/$20 Brand/30 days(1)	$10 Generic/$20 Brand
*Mail service Rx	2x$10/$20/90 days(1)	2x$10/$20/100 days(1)	2x$10/$20/90 days(1)	$20/40 90 days
*DME	No Charge	No Charge	No Charge	No Charge
*Ambulance	No Charge	No Charge	No Charge	No Charge
*Emergency room(3)	$50 (3)	$50 (3)	$50 (3)	$35
*Urgent care	$20	$20	$20	$35
*Vision (1)	$20 (to 18 yrs) (1)	$20 (no age limit) (1)	$20 (to 18 yrs) (1)	$20 (1)
*Dental Procedures	No Charge	No Charge	No Charge	See Brochure
No charge if due to
underlying medical
condition
*Blood & blood products	No Charge	No Charge	No Charge	See Brochure
*Health Education	No Charge	Programs Vary	Programs Vary	No Charge
*Transplants	No Charge	No Charge	No Charge	No Charge
*Chiropractor	$15/20 visits (1)	$15/20 visits (1)	$15/20 visits (1)	$15/20 visits (1)

MENTAL HEALTH:
*Inpatient (5)	No Charge x 30 days	No Charge x 30 days	No Charge x 30 days	No Charge
*Outpatient (5)	$20 x 20 visits	$20 x 20 visits	$20 x 20 visits	$35 x 20 visits annual
*Outpatient SMI Diagnosis(5)	$20	$20	$20	$20

SUBSTANCE ABUSE:
*Inpatient (detox) (1)	No Charge	No Charge	No Charge	No Charge
*Outpatient	$20 x 20 visits	$20 Ind. Therapy (1)	$20 x 20 visits	See Brochure

RATES:
*Employee Only	$251.67	$273.78	$274.91	$366.30
*Employee +1	$503.33	$547.56	$549.82	$772.80
*Family	$679.49	$739.20	$742.25	$1,106.09

Notes:
(1) See specific benefit language for complete benefits
(2) Read benefit language for maximums
(3) Waive if admitted
(5) See language for parity diagnoses

MEDICAL COVERAGE - 100% COUNTY PAID AT BASE LEVEL

CREDIT - BASE COVERAGE AT LOWEST COST OPTION (HPSJ HMO) PER SEMI MONTHLY

Employee Only Employee + One Employee + Family

$251.67 $503.33 $679.49

The above information is only a summary of benefits - please refer to the booklet for each carrier for complete descriptions, exclusions and limitations.

Revised 10/24/2008