Riverside County Electrical Health & Welfare Plan

Medical Plan Options

Participants in the Riverside County Electrical Health & Welfare Plan may select from three medical plans: the Self-Funded PPO Plan, the Aetna HMO and the Kaiser HMO.  

The Self-Funded PPO Plan allows you to see any doctor, whether or not they are part of the network. With this plan, you pay annual deductibles before the plan pays any benefits. You may visit any provider, but your out-of-pocket costs will be less if you utilize a PPO provider. The PPO network is the Anthem Blue Cross Prudent Buyer Network for medical services provided in California. For medical services provided outside California, the PPO network is First Health. 

Under the HMO options (Aetna & Kaiser), you must select a Primary Care Physician. This is the doctor you must always visit for all of your care. If you need to see a Specialist, your doctor will refer you to another doctor for the necessary services. With an HMO, you do not pay an annual deductible and only pay a small fee for office visits.  Kaiser participants must visit Kaiser facilities. 

This chart will help you to compare many plan features side-by-side:

  Self-Funded PPO Plan

Aetna HMO
Kaiser
Network Enrollees in the PPO Plan may visit any provider. Your benefits are higher if you use PPO providers who are contracted with the Anthem Blue Cross Prudent Buyer Network. Enrollees in Aetna must receive all care at the Medical Group in which you enroll. Each family member may select a different Primary Care Physician (PCP).  Care not authorized by your Primary Care Physician is not covered. Enrollees in Kaiser must receive all their care at Kaiser clinics and hospitals.
Deductible PPO:  $200 per individual; $400 per family

Non-PPO:  $250 per individual; $5000 per family

 

 None None
Coinsurance/Co-Pays PPO Office Visits:  $15 copay
Coinsurance:  PPO- 80% of contracted rate; non-PPO - 80% of Usual, Customary & Reasonable.

 

 Office Visits:  $15
Hospitalization:  -0-
Emergency Room:  $50 		Office Visits: $15
(maternity/well child care:  $5)
Hospitalization: -0-
Urgent Care Center $15
Emergency Room $50
Out of Pocket Maximum per calendar year PPO:  $2,500 per person.
Non-PPO:  $10,000 per person 		$1,500 per person/$3,000 per family $1,500 per person/$3,000 per family
Prescription Drug

Express Scripts Card--   
Retail:  $5 generic/$25 brand preferred/$45 brand non-preferred, up to a 30-day supply. 
Mail Order:  $10 generic/$50 brand preferred/$90 brand non-preferred, up to a 90-day supply. 

Select Home Delivery Program for Maintenance Drugs:  If you have a prescription for maintenance drugs, you must transition to the mail order program by the third dispensing of the prescription, unless you choose to opt out of this program.

 $10 generic/ $20 brand formulary/ $35 brand nonformulary Retail: $10 generic/$20 brand name, up to 30-day supply.
Mail Order: $20 generic/$40 brand name up to 100-day supply.


 
Benefits provided under the PPO Medical Plan are subject to compliance with the requirements of the Utilization Management Program.  Refer to your Summary Plan Description (SPD) for details.

This group health plan believes it is a “grandfathered health plan” under the Patient Protection and Affordable Care Act. Because of this, certain provisions under the Affordable Care Act do not apply to this group health plan. See here for more information.