Labor Group

Benefit

Traditional Medical

(Preferred)

Managed Care Medical (Prime)

Comment

Non-Represented, Retirees, Elected Officials

Annual Deductible

$100 per enrollee to 3 enrollees per family

$10 – visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$1,500 per enrollee to 3 enrollees per family

$1,000 per enrollee

Prescription Drug Program

Formulary - $15/$30/$35, no maximum out of pocket

Formulary - $15/$30/$35, no maximum out of pocket

AFSCME

AFSCME Nurses

Annual Deductible

$125 – per enrollee to 3 enrollees per family

$20/visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual  Out of Pocket

$500 per each enrollee

$1,000 each enrollee

Prescription Drug Program

$100 annual deductible per enrollee to 3 enrollees per family;

20% cost to a $400 max out of pocket per enrolleeEnrollee pays 

$100 annual deductible per enrollee to 3 enrollees per family;

20% cost to a $400 max out of pocket per enrollee

AFSCME Nurses

Annual Deductible

$125 – per enrollee to 3 enrollees per family

$20-visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$500 per each enrollee

$1,000 each enrollee

Prescription Drug Program

$100 annual deductible per enrollee to 3 enrollees per family;

20% cost to a $400 max out of pocket per enrolleeEnrollee pays

$100 annual deductible per enrollee to 3 enrollees per family;

20% cost to a $400 max out of pocket per enrollee

Administrative - Professional

Annual Deductible

$100 per enrollee – 3 enrollees per family

$10 – visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$1,000 per enrollee to 3 enrollees per family

$1,000 per enrollee

Prescription Drug Program

Formulary - $10/$20/$25, no maximum out of pocket

Formulary - $10/$20/$25, no maximum out of pocket

Labor Group

Benefit

Traditional Medical

(Preferred)

Managed Care Medical (Prime)

Comment

LCPOA

Annual Deductible

$100 per enrollee to 3 enrollees per family

$5 – visit co-pay

Annual deductible is combined medical/rx

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$500 per enrollee

$1,000 per enrollee

Prescription Drug Program

Medical and Rx maximum out of pocket is combined

$50 annual deductible per enrollee to 3 enrollees per family;

20% cost to a $500 max out of pocket per enrollee

Other Medical Benefits Specific to Group

DIRECTION Pre-Authorization is not required for out patient MH/CD

Vision benefit is annual for adults and children

Cost Share

Employee pays 50% of any composite premium cost increase over 10%

Current Cost share amount $0

 - reviewed annually for August 01 adjustment

LCPWA –

Local 626

Annual Deductible

$100 per enrollee to 3 enrollees per family

$10 – visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$1,500 per enrollee to 3 enrollees per family

$1,000 per enrollee

Prescription Drug Program

Formulary - $15/$30/$35, no maximum out of pocket

Formulary - $15/$30/$35, no maximum out of pocket

Prosecuting Attorneys

Annual Deductible

$100 per enrollee to 3 enrollees per family

$10 – visit co-pay

Basic Benefit Design

Pacific Source Preferred Provider paid at 100% after annual deductible

Pacific Source Primary Care Provider (PCP) and Specialist (with PCP referral) paid 100% following per visit co-pay

Maximum Annual Out of Pocket

$1,000 per enrollee to 3 enrollees per family

$1,000 per enrollee

Prescription Drug Program

Formulary - $10/$20/$25, no maximum out of pocket

Formulary - $10/$20/$25, no maximum out of pocket