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Medical Plan Comparison Charts

View side by side comparisons of the CHP EPO and PPO, Traditional HMO, Hospital Services DHMO, Deductible First HDHP and Medicare plans. The benefits listed are effective for the plan year June 1, 2024 - May 31, 2025.

Employee Semi-Monthly Medical Premiums

Extra Help Semi-Monthly Medical Premiums

Retriee Monthly Medical Premiums

County Health Plan EPO and PPO

Deductible and Out of Pocket Maximums

Plan Information	County Health Plan EPO	County Health Plan PPO
Health Plan Availability	Nationwide	Nationwide
Select a Primary Care Physician (PCP)	Does not require you to select a PCP	Does not require you to select a PCP
Seeing a Specialist	Allows you access to many types of services without receiving a referral or advance approval	Allows you access to many types of services without receiving a referral or advance approval
Dependent Children Eligibility	Dependent child under age 26 Disabled: No age limit	Dependent child under age 26 Disabled: No age limit
Plan Year (June 1 to May 31) Medical Deductible	Individual: $500 Family: $1,500	Individual: $300 Family: $900
Plan Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance)	Medical/Prescription Drug Individual: $5,500/$1,100 Family: $11,500/$1,700	Medical/Prescription Drug Individual: $2,300/$1,100 Family: $4,900/$1,700

Office Visits and Professional Services

Plan Information	County Health Plan EPO	County Health Plan PPO
Physician and Specialist	In-Network: $50 copay, no deductible LiveHealth Online: $10 copay Out-of-Network: Not covered	In-Network: $20 copay, no deductible LiveHealth Online: $10 copay Out-of-Network: 40% coinsurance after deductible
Preventive Care Birth to Age 18	In-Network: No charge, no deductible Out-of-Network: Not covered	In-Network: No charge, no deductible< Out-of-Network: 40% coinsurance after deductible
Preventive Care Adult Routine Care	In-Network: No charge, no deductible Out-of-Network: Not covered	In-Network: No charge, no deductible Out-of-Network: Not covered
Preventive Care Adult Routine OB/GYN	In-Network: No charge, no deductible Out-of-Network: Not covered	In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible
Diagnostic Imaging, Lab and X-ray	In-Network: 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Physical Therapy (medical necessary treatment only)	In-Network: 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Chiropractic and Acupucture	In-Network: 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Mental Health and Substance Abuse Disorder (Outpatient)	In-Network: Office Visit: $50 copay, no deductible Other Outpatient: 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: Office Visit: $20 copay, no deductible Other Outpatient: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Family Planning Counseling and Consultation	In-Network: $50 copay, no deductible Out-of-Network: Not covered	In-Network: $20 copay, no deductible Out-of-Network: 40% coinsurance after deductible
Routine Eye Exams with Plan Optometrist	In-Network: No charge, no deductible Out-of-Network: Not covered	In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible
Hearing Exam	In-Network: No charge, no deductible Out-of-Network: Not covered	In-Network: No charge, no deductible Out-of-Network: 40% coinsurance after deductible
Allergy Injections (serum included)	In-Network: $50 copay, no deductible, per visit Out-of-Network: Not covered	In-Network: $20 copay, no deductible, per visit Out-of-Network: 40% coinsurance after deductible
Infertility Services	Evaluation (diagnosis) and surgical repair only In-Network: $50 copay, no deductible Out-of-Network: Not covered	Evaluation (diagnosis) and surgical repair only In-Network: $20 copay, no deductible Out-of-Network:40% coinsurance, after deductible

Surgical and Hospital Services

Plan Information	County Health Plan EPO	County Health Plan PPO
Hospital and Physician/Surgeon Services	In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible
Outpatient Surgery	In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Maternity	In-Network: $250 copay plus 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible
Emergency Room	In-Network: $150 copay plus 20% coinsurance after deductible if emergency; otherwise not covered Out-of-Network: $150 copay plus 20% coinsurance after deductible if emergency; otherwise not covered (copays waived if admitted)	In-Network: $100 copay plus 10% coinsurance after deductible if emergency Out-of-Network: $100 copay plus 10% coinsurance after deductible; If an emergency (copays waived if admitted)
Ambulance	In-Network: 20% coinsurance after deductible Out-of-Network: 20% coinsurance after deductible if emergency; otherwise not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 10% coinsurance after deductible if emergency otherwise not covered
Mental Health and Substance Abuse Disorder (Inpatient)	In-Network: $500 copay plus 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: $125 per admission copay plus 10% coinsurance after deductible Out-of-Network: $125 per admission copay plus 40% coinsurance after deductible
Skilled Nursing Facility	In-Network: Not covered Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Up to 100 days per plan year Out-of-Network: 40% coinsurance after deductible Up to 100 days per plan year
Home Health	In-Network: Not covered Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Up to 100 visits per plan year Out-of-Network: 40% coinsurance after deductible Up to 100 visits per plan year
Urgent Care	In-Network: $50 copay, no deductible Out-of-Network: Not covered	In-Network: $20 copay, no deductible Out-of-Network: 40% coinsurance, after deductible
Hearing Aids	One per ear every 36 months	One per ear every 36 months
Durable Medical Equipment	In-Network: 20% coinsurance after deductible Out-of-Network: Not covered	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible

Prescription Drugs

Plan Information	County Health Plan EPO	County Health Plan PPO
Generic or Tier 1	$10 copay Up to 34 day supply	$5 copay Up to 34 day supply
Formulary Brand or Tier 2	$35 copay Up to 34 day supply	$20 copay Up to 34 day supply
Non-Formulary Brand or Tier 3	$70 copay Up to 34 day supply	$40 copay Up to 34 day supply
Mail Order Benefit Generic or Tier 1	$20 copay Up to 90 day supply	$10 copay Up to 90 day supply
Mail Order Benefit Formulary Brand or Tier 2	$70 copay Up to 90 day supply	$40 copay Up to 90 day supply
Mail Order Benefit Non-Formulary Brand or Tier 3	$140 copay Up to 90 day supply	$80 copay Up to 90 day supply
Mandatory Mail Order	Yes, through CVS Pharmacy Benefit	Yes, through CVS Pharmacy Benefit
Mandatory Generic Program	Yes	Yes

Traditional HMO

Deductible and Out of Pocket Maximums

Office Visits and Professional Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Physician and Specialist Office Visits	$10 copay	$10 copay Telehealth: $5 copay	$10 copay
Preventive Care Birth to Age 18	No charge	No charge	No charge
Preventive Care Adult Routine Care	No charge	No charge	No charge
Preventive Care Adult Routine OB/GYN	No charge	No charge	No charge
Diagnostic Imaging, Lab and X-ray	No charge	No charge	No charge
Physical Therapy (medical necessary treatment only)	$10 copay	$10 copay	$10 copay
Chiropractic and Acupuncture	Discounted rates through Kaiser Choose Healthy	Chiropractic: $10 copay Up to 20 visits per year (Chiropractic services do not apply to out-of-pocket maximum) Acupuncture: PCP referral $10 copay LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain.	Chiropractic: $15 copay Up to 20 visits per year - Copays do not contribute to out-of-pocket maximum Acupuncture: $15 copay Up to 20 visits per year
Mental Health and Substance Abuse Disorder (Outpatient)	Individual: $10 copay Group: $5 copay	www.liveandworkwell.com Individual: $10 copay Telehealth: $5 copay Group: $5 copay	www.liveandworkwell.com $10 copay per office or virtual visit Outpatient services: No copay
Family Planning Counseling and Consultation	No charge	No charge	No charge
Routine Eye Exams with Plan Optometrist	No charge	No charge	No charge
Hearing Exam	No charge	No charge	No charge
Allergy Injections (serum included)	$3 copay	$10 copay with a PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge)	$3 copay
Infertility Services	$10 copay	50% Coinsurance (Infertility services do not apply to out-of-pocket maximum)	$10 copay Copays do not contribute to out-of-pocket maximum

Surgical and Hospital Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Hospitalization and Physician/Surgeon Services	Facility Fee: No charge Physician/Surgeon Fee: No charge	Facility Fee: No charge Physician/Surgeon Fee: No charge	Facility Fee: No charge Physician/Surgeon Fee: No charge
Outpatient Surgery	$10 copay	$10 copay	$10 copay
Maternity	No charge	No charge	No charge
Emergency Room	$50 copay(waived if admitted)	$50 copay(waived if admitted)	$50 copay(waived if admitted)
Ambulance	$50 per trip	$50 per trip	$50 per trip
Mental Health and Substance Abuse Disorder (Inpatient)	No charge	No charge	No charge
Skilled Nursing Facility	No charge Up to 100 days per benefit period	No charge Up to 100 days per benefit period	No charge Up to 100 days per benefit period
Home Health	No charge Up to 100 visits per year	No charge Up to 100 visits per year	No charge Up to 100 visits per year
Urgent Care	$10 copay	$10 copay	$10 copay
Hearing Aids	Not covered	Not covered	Not covered
Durable Medical Equipment	20% coinsurance in accordance with formulary	No charge	20% coinsurance - based on WHA's contracted rates with providers

Prescription Drugs

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Generic or Tier 1	$5 copay Up to 100 day supply	$5 copay Up to 30 day supply	$5 copay Up to 30 day supply
Formulary Brand or Tier 2	$10 copay Up to 100 day supply	$10 copay Up to 30 day supply	$10 copay Up to 30 day supply
Non-Formulary Brand or Tier 3	$10 copay Up to 100 day supply	Tier 3: $20 copay Up to 30 day supply Tier 4 (Specialty Drug): $20 copay Up to a 30 day supply only	$20 copay Up to 30 day supply
Mail Order Benefit Generic or Tier 1	$5 copay Up to 100 day supply	$10 copay Up to 100 day supply	$5 copay Up to 90 day supply
Mail Order Benefit Formulary Brand or Tier 2	$10 copay Up to 100 day supply	$20 copay Up to 100 day supply	$10 copay Up to 90 day supply
Mail Order Benefit Non-Formulary Brand or Tier 3	$10 copay Up to 100 day supply	$40 copay Up to 100 day supply	$20 copay Up to 90 day supply
Mandatory Mail Order	No	No	No
Mandatory Generic Program	N/A	Dispense as written program	Yes

Hospital Services DHMO

Deductible and Out of Pocket Maximums

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Health Plan Availability	Based on residential zip code. Must live or work in the service area within California	Based on residential zip code. Must live or work in the service area within Northern California	Based on residential zip code. Each person enrolled must live or work in the service area within Northern California
Select A Primary Care Physician (PCP)	Requires you to select a PCP who will work with you to manage your health care needs	Requires you to select a PCP who will work with you to manage your health care needs	Requires you to select a PCP who will work with you to manage your health care needs
Seeing a Specialist	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests
Dependent Children Eligibility	Dependent child under age 26 Disabled: No age limit	Dependent child under age 26 Disabled: No age limit	Dependent child under age 26 Disabled: No age limit
Calendar Year Deductible	Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000	Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000	Individual: $1,000 Any One Member in a family of two or more: $1,000 Family of two or more: $2,000
Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance)	Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000	Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000	Individual: $3,000 Any One Member in a family of two or more: $3,000 Family of two or more: $6,000

Office Visits and Professional Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Physician and Specialist Office Visits	$20 copay, no deductible	$20 copay, no deductible Telehealth: $10 copay, no deductible	$20 copay, no deductible
Preventive Care Birth to Age 18	No charge, no deductible	No charge, no deductible	No charge, no deductible
Preventive Care Adult Routine Care	No charge, no deductible	No charge, no deductible	No charge, no deductible
Preventive Care Adult Routine OB/GYN	No charge, no deductible	No charge, no deductible	No charge, no deductible
Diagnostic Imaging, Lab and X-ray	Diagnostic Lab: $10 copay per encounter, no deductible Diagnostic X-ray: $10 copay per encounter, no deductible CT/PET Scans & MRI: $50 per procedure, no deductible	Diagnostic Lab: $20 copay per encounter, no deductible Diagnostic X-ray: $10 copay per encounter, no deductible CT/PET Scans & MRI: $50 per procedure, no deductible	Diagnostic Lab: No charge, no deductible Diagnostic X-ray: No charge, no deductible
Physical Therapy (Medical necessary treatment only)	$20 copay , no deductible	$20 copay , no deductible	$20 copay , no deductible
Chiropractic and Acupuncture	Discounted rates through Kaiser Choose Healthy	Chiropractic: $20 copay Up to 20 visits per year (Chiropractic services do not apply to out-of-pocket maximum) Acupuncture: PCP referral $20 copay LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain.	Chiropractic: $15 copay Up to 20 visits per year - Copays do not contribute to out-of-pocket maximum Acupuncture: $15 copay, no deductible. Up to 20 visits per year
Mental Health and Substance Abuse Disorder (Outpatient)	MH/SUD Individual: $20 copay, no deductible MH group: $10 copay, no deductible SUD group: $5 copay, no deductible	www.liveandworkwell.com MH/SUD Individual: $20 copay, no deductible MH/SUD group: $10 copay, no deductible	www.liveandworkwell.com $20 copay, no deductible, per office or virtual visit Outpatient services: No copay, no deductible
Family Planning Counseling and Consultation	No charge, no deductible	No charge, no deductible	No charge, no deductible
Routine Eye Exams with Plan Optometrist	No charge, no deductible	No charge, no deductible	No charge, no deductible
Hearing Exam	No charge, no deductible	No charge, no deductible	No charge, no deductible
Allergy Injections (serum included)	No charge, no deductible	$20 copay, no deductible with a PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge, no deductible)	No charge, no deductible
Infertility Services	50% coinsurance, no deductible	50% coinsurance, no deductible (Infertility services do not apply to out-of-pocket maximum)	50% coinsurance, no deductible Copays do not contribute to out-of-pocket maximum

Surgical and Hospital Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Hospitalization and Physician/Surgeon Services	20% coinsurance after deductible	20% coinsurance after deductible	20% coinsurance after deductible
Outpatient Surgery	20% coinsurance after deductible	20% coinsurance after deductible	$20 copay per visit, no deductible, performed in office setting 20% coinsurance after deductible, performed in facility
Maternity	20% coinsurance after deductible	20% coinsurance after deductible	20% coinsurance after deductible
Emergency Room	20% coinsurance after deductible	20% coinsurance after deductible	20% coinsurance after deductible
Ambulance	$150 per trip, no deductible	No charge after deductible	$150 per trip, no deductible
Mental Health Substance Abuse Disorder (Inpatient)	20% coinsurance after deductible	20% coinsurance after deductible	20% coinsurance after deductible
Skilled Nursing Facility	20% coinsurance, no deductible Up to 100 days per benefit period	20% coinsurance after deductible Up to 100 days per benefit period	20% coinsurance, no deductible Up to 100 days per benefit period
Home Health	No charge, no deductible Up to 100 visits per year	No charge, no deductible Up to 100 visits per calendar year	No charge, no deductible Up to 100 visits per year
Urgent Care	$20 copay, no deductible	$20 copay, no deductible	$20 copay, no deductible
Hearing Aids	Not covered	Not covered	Not covered
Durable Medical Equipment	20% coinsurance in accordance with formulary, no deductible	20% coinsurance after deductible	20% coinsurance, no deductible

Prescription Drugs

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Generic or Tier 1	$10 copay, no deductible Up to 30 day supply	$10 copay, no deductible Up to 30 day supply	$10 copay, no deductible Up to 30 day supply
Formulary Brand or Tier 2	$30 copay, no deductible Up to 30 day supply	$30 copay, no deductible Up to 30 day supply	$30 copay, no deductible Up to 30 day supply
Non-Formulary Brand or Tier 3	$30 copay, no deductible Up to 30 day supply (Must be deemed medically necessary under the treatment of the Kaiser physician)	Tier 3: $60 copay, no deductible Up to 30 day supply Tier 4 (Specialty Drug): 20% coinsurance ($100 per prescription maximum), no deductible Up to 30 day supply	$50 copay, no deductible Up to 30 day supply
Mail Order Benefit Generic or Tier 1	$20 copay, no deductible Up to 100 day supply	$20 copay, no deductible Up to 100 day supply	$20 copay, no deductible Up to 90 day supply
Mail Order Benefit Formulary Brand or Tier 2	$60 copay, no deductible Up to 100 day supply	$60 copay, no deductible Up to 100 day supply	$60 copay, no deductible Up to 90 day supply
Mail Order Benefit Non-Formulary Brand or Tier 3	$60 copay, no deductible Up to 100 day supply	$120 copay, no deductible Up to 100 day supply	$100 copay, no deductible Up to 90 day supply
Mandatory Mail Order	No	No	No
Mandatory Generic Program	N/A	Dispense as written program	Yes

Deductible First HDHP

Deductible and Out of Pocket Maximums

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Health Plan Availability	Based on residential zip code. Must live or work in the service area within California	Based on residential zip code. Must live or work in the service area within Northern California	Based on residential zip code. Each person enrolled must live or work in the service area within Northern California
Select A Primary Care Physician (PCP)	Requires you to select a PCP who will work with you to manage your health care needs	Requires you to select a PCP who will work with you to manage your health care needs	Requires you to select a PCP who will work with you to manage your health care needs
Seeing a Specialist	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests
Dependent Children Eligibility	Dependent child under age 26 Disabled: No age limit	Dependent child under age 26 Disabled: No age limit	Dependent child under age 26 Disabled: No age limit
Calendar Year Deductible	Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200	Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200	Individual: $1,600 Any One Member in a family of two or more: $3,200 Family of two or more: $3,200
Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays Coinsurance)	Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400	Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400	Individual: $3,200 Any One Member in a family of two or more: $3,200 Family of two or more: $6,400

Office Visits and Professional Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Physician and Specialist office visits	$20 copay after deductible	$20 copay after deductible Telehealth: $10 copay after deductible	$20 copay after deductible
Preventive Care Birth to Age 18	No charge, no deductible	No charge, no deductible	No charge, no deductible
Preventive Care Adult Routine Care	No charge, no deductible	No charge, no deductible	No charge, no deductible
Preventive Care Adult Routine OB/GYN	No charge, no deductible	No charge, no deductible	No charge, no deductible
Diagnostic Imaging, Lab and X-ray	Diagnostic Lab: $10 copay after deductible, per encounter Diagnostic X-ray: $10 copay after deductible, per encounter CT/PET Scans & MRI: $50 per procedure after deductible	Diagnostic Lab: $20 copay after deductible Diagnostic X-ray: $10 copay after deductible, per procedure CT/PET Scans & MRI: $50 copay after deductible, per procedure	No charge after deductible
Physical Therapy (medical necessary treatment only)	$20 copay after deductible	$20 copay after deductible	$20 copay after deductible
Chiropractic and Acupuncture	Discounted rates through Kaiser Choose Healthy	Chiropractic: Not covered Acupuncture: PCP referral $20 copay after deductible LIMITED benefit for the treatment of nausea or as part of pain management program for chronic pain	No charge after deductible Up to 20 visits per year
Mental Health and Substance Abuse Disorder (Outpatient)	MH/SUD individual: $20 copay after deductible MH group: $10 copay after deductible SUD group: $5 copay after deductible	www.liveandworkwell.com MH/SUD individual: $20 copay after deductible, per visit Virtual Visit: $10 copay after deductible MH/SUD group: $10 copay after deductible, per visit	www.liveandworkwell.com $20 copay after deductible, per office or virtual visit Outpatient services: No copay, after deductible
Family Planning Counseling and Consultation	No charge, no deductible	No charge, no deductible	$20 copay after deductible
Routine Eye Exams with Plan Optometrist	$20 copay, no deductible	No charge, no deductible	No charge, no deductible
Hearing Exam	No charge, no deductible	No charge, no deductible	No charge, no deductible
Allergy Injections (serum included)	$5 copay after deductible	$20 copay after deductible with PCP or Specialist (Visits where only an injection is received without seeing a PCP or Specialist are no charge, after deductible)	$5 copay after deductible
Infertility Services	Not covered	Not covered	50% coinsurance, no deductible Copays do not contribute to out-of -pocket maximum

Surgical and Hospital Services

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Hospitalization and Physician/Surgeon Services	$250 copay after deductible, per admission Inpatient Physician Services: No charge after deductible	Hospitalization Facility Fee: $250 copay after deductible, per day Up to 5 days per admission Inpatient Physician Services: No charge after deductible	$250 copay after deductible, per admission Inpatient Physician Services: No charge after deductible
Outpatient Surgery	$150 copay after deductible, per procedure	$20 copay after deductible, per visit	$150 copay after deductible, per procedure
Maternity	$250 copay after deductible, per admission	Hospitalization Facility Fee: $250 copay per day after deductible Up to 5 days per admission Inpatient Physician Services: No charge after deductible	$250 copay after deductible, per admission
Emergency Room	$100 copay after deductible	$100 copay after deductible	$100 copay after deductible
Ambulance	$100 copay after deductible, per trip	$100 copay per trip, after deductible	$100 copay after deductible, per trip
Mental Health & Substance Abuse Disorder (Inpatient)	$250 copay after deductible, per admission	MH/SUD Inpatient Facility: $250 copay per day after deductible Up to 5 days per admission MH/SUD Inpatient Physician Services: No charge after deductible	$250 copay after deductible, per admission
Skilled Nursing Facility	$250 copay after deductible, per admission Up to 100 days per benefit period	$100 copay after deductible, per day Up to 5 days per admission Up to 100 days per benefit period	$250 copay after deductible, per admission Up to 100 days per benefit period
Home Health	No charge after deductible Up to 100 visits per year	No charge after deductible Up to 100 visits per year	No charge after deductible Up to 100 visits per year
Urgent Care	$20 copay after deductible	$20 copay after deductible	$20 copay after deductible
Hearing Aids	Not covered	Not covered	Not covered
Durable Medical Equipment	20% coinsurance after deductible in accordance with formulary	20% coinsurance after deductible	20% coinsurance after deductible

Prescription Drugs

Plan Information	Kaiser Permanente	Sutter Health Plan	Western Health Advantage
Generic or Tier 1	$10 copay after deductible Up to 30 day supply	$10 copay after deductible Up to 30 day supply	$10 copay after deductible Up to 30 day supply
Formulary Brand or Tier 2	$30 copay after deductible Up to 30 day supply	$30 copay after deductible Up to 30 day supply	$30 copay after deductible Up to 30 day supply
Non-Formulary Brand or Tier 3	$30 copay Up to 30 day supply after deductible (Must be deemed medically necessary under the treatment of the Kaiser physician)	Tier 3:$60 copay after deductible Up to 30 day supply Tier 4 (Specialty Drug):20% coinsurance ($100 per prescription maximum) after deductible Up to 30 day supply	$50 copay after deductible Up to 30 day supply
Mail Order Benefit Generic or Tier 1	$20 copay after deductible Up to 100 day supply	$20 copay after deductible Up to 100 day supply	$20 copay after deductible Up to 90 day supply
Mail Order Benefit Formulary Brand or Tier 2	$60 copay after deductible Up to 100 day supply	$60 copay after deductible Up to 100 day supply	$60 copay after deductible Up to 90 day supply
Mail Order Benefit Non-Formulary Brand or Tier 3	$60 copay after deductible Up to 100 day supply	$120 copay after deductible Up to 100 day supply	$100 copay after deductible Up to 90 day supply
Mandatory Mail Order	No	No	No
Mandatory Generic Program	N/A	Dispense as written program	Yes

Medicare Plans

Deductible and Out of Pocket Maximums

Plan Information	Kaiser Permanente Senior Advantage	Anthem Blue Cross Medicare Advantage PPO
Health Plan Availability	Based on residential zip code. Must live in service area within California, Hawaii, and the Northwest (Oregon/ Washington); rates vary by state	Nationwide
Select a Primary Care Physician (PCP)	Requires you to select a PCP who will work with you to manage your health care needs	Does not require you to select a PCP
Seeing a Specialist	Requires advance approval from the medical group or health plan for some services, such as treatment by a specialist or certain types of tests	Allows you access to many types of services without receiving a referral or advance approval
Dependent Children Eligibility	Dependent child under age 26 Disabled: No age limit	Medicare eligible only
Calendar Year Deductible	None	None
Calendar Year Out-of-Pocket Maximum (including Deductibles, Copays & Coinsurance)	Individual: $1,500 Any One Member in a family of two or more: $1,500 Family of two or more: $3,000	Medical: None Prescription Drug: $8,000 True Out-of-Pocket

Office Visits and Professional Services

Plan Information	Kaiser Permanente Senior Advantage	Anthem Blue Cross Medicare Advantage PPO
Physician and Specialist Office Visits	$10 copay after deductible	No charge
Preventive Care Birth to Age 18	No charge, no deductible	N/A
Preventive Care Adult Routine Care	No charge, no deductible	No charge
Preventive Care Adult Routine OB/GYN	No charge, no deductible	No charge
Diagnostic Imaging, Lab and X-ray	No charge	No charge
Physical Therapy (medical necessary treatment only)	$10 copay	No charge
Chiropractic and Acupuncture	Discounted rates through Kaiser Choose Healthy (California only)	No charge
Mental Health and Substance Abuse Disorder (Outpatient)	Individual: $10 copay Group: $5 copay	No charge

Surgical and Hospital Services

Plan Information	Kaiser Permanente Senior Advantage	Anthem Blue Cross Medicare Advantage PPO
Hospitalization and Physician/Surgeon Services	Facility Fee: No charge Physician/Surgeon Fee: No charge	No charge
Outpatient Surgery	$10 copay	No charge
Maternity	No charge	No charge
Emergency Room	$50 copay (waived if admitted)	$100 copay
Ambulance	$50 per trip	No charge
Mental Health and Substance Abuse Disorder (Inpatient)	No charge	No charge
Skilled Nursing Facility	No charge Up to 100 days per benefit period	No charge
Home Health	No charge Up to 100 visits per year	No charge
Hearing Aids	Not covered	$500 per ear with a maximum benefit of $1000 per ear every three calendar years

Prescription Drugs

Plan Information	Kaiser Permanente Senior Advantage	Anthem Blue Cross Medicare Advantage PPO
Generic or Tier 1	$5 copay Up to 100 day supply	$5 copay Up to 30 day supply
Formulary Brand or Tier 2	$10 copay Up to 100 day supply	$10 copay Up to 30 day supply
Non-Formulary Brand or Tier 3	$10 copay Up to 100 day supply	$10 copay Up to 30 day supply
Mail Order Benefit Generic or Tier 1	$5 copay Up to 100 day supply	$10 copay Up to 90 day supply
Mail Order Benefit Formulary Brand or Tier 2	$10 copay Up to 100 day supply	$20 copay Up to 90 day supply
Mail Order Benefit Non-Formulary Brand or Tier 3	$10 copay Up to 100 day supply	$20 copay Up to 90 day supply
Mandatory Mail Order	No	No
Mandatory Generic Program	No	No

Employee Assistance Program

EAP provides up to six sessions with a licensed counselor to provide guidance and support to help you and your family manage daily stresses, grievance, traumatic events and develop fulfilling relationships both personally and professionally. EAP is available to all County of Sonoma employees and their family members.

CareCounsel Health Advocacy

CareCounsel's Health Advocacy program is a special benefit sponsored by the County that can help you understand and effectively navigate your health benefits.

Mid-Year Enrollment Changes

Have a qualifying Mid-Year Event? Life and employment changes may affect your health benefit options. Find out if you have a qualifying event, per the IRC Section 125, that will allow you to make changes to your benefits.

Benefit Forms, Plan Documents and Important Information

Find all the forms you need to enroll, change or cancel your benefits. Looking for plan information? You can find Summary of Benefits and Coverages (SBC's) and Evidence of Coverage (EOC's, detailed plan information) in plan documents.