California associate medical coverage
At IMA, our goal is to help you reach your highest potential and be the best version of yourself. This starts with taking care of your overall health. You and your eligible family members can choose from three medical plans:
The Blue Option PPO and Green Option Qualified HDHP are administered by AmeriBen and use the Anthem nationwide network of providers and facilities. Although both plans offer you the freedom and flexibility to see any doctor, you will save the most money by staying in-network for care. To find a provider, visit anthem.com/find-care.
The Kaiser Traditional HMO allows California associates only, to access the Kaiser network of providers and hospitals. Coverage under the HMO is only available through providers and facilities that are in-network. If you visit a doctor that is not in the HMO network, you are responsible for 100% of the cost of services. To find an in-network Kaiser provider, go to kp.org and update the region on the top right corner of the page, then select Doctors & Location to begin your search.
When deciding which medical plan is right for you and your family, it is important to consider the total cost of coverage. This includes what you pay in premiums and what you pay for services out of your pocket. While all three medical plans cover in-network preventive screenings in full, the plans vary on annual deductibles, copays and levels of coinsurance. The ideal medical plan should cover most of your health needs with out-of-pocket costs that meet your budget.
The Blue Option PPO allows you to choose a primary care physician (PCP) to help coordinate your medical needs or you can see any specialist in the network on your own, without a referral.
While your monthly premium is higher than the Green Option Qualified HDHP, you will pay a lower annual deductible. Both preventive and virtual care services are 100% covered. Once you meet your deductible, the Blue Option PPO generally pays 80% of eligible healthcare costs.
You can contribute pre-tax dollars to a Healthcare Flexible Spending Account to pay for eligible healthcare expenses.
The Green Option Qualified HDHP offers a variety of benefits, like lower monthly premiums and a tax-advantaged account, but it’s important to understand how the plan works to see if it’s the right choice for you.
You will pay 100% of the costs for medical care until you reach the deductible of $3,400 individual / $6,800 family (embedded deductible). You can use your Health Savings Account (HSA) dollars to pay for expenses tax-free.
After you reach your deductible, the plan pays 100% of eligible medical and prescription costs for the rest of the plan year.
The Kaiser Traditional HMO plan allows California associates to select an in-network primary care physician (PCP) that coordinates all of your medical needs. When care is required outside the PCP, you’ll be required to get a referral. The HMO plan does not allow for out of network visits.
While your monthly premium may be comparable to other available plan options, you’ll notice there is no deductible on this plan and most visits require a set copay amount.
Under an HMO plan, your primary care physician will direct all of your care, meaning you must receive a referral in order to see a specialist. In addition, under an HMO plan you are required to use an in-network provider. When you choose to go outside the network, you are responsible for 100% of the cost.
| Plan Features | Kaiser Traditional HMO (CA Only) | AmeriBen Blue Option PPO | AmeriBen Green Option QHDHP |
|---|---|---|---|
| In-Network Only | In-Network | In-Network | |
| Network Access | Kaiser Permanente | National PPO (BlueCard PPO) Preferred Blue Option-Utah only |
|
| Annual Deductible Individual/Family | None | $1,000 / $2,000 | $3,400 / $6,800 |
| Annual Out-of-Pocket Maximum Individual/Family | $1,500 / $3,000 | $4,000 / $8,000 | $3,400 / $6,800 |
| IMA Annual HSA Contribution (pro-rated) Individual/Family | N/A | N/A | $500 / $1,000 |
| FSA Eligibility | General Purpose Healthcare and/or Dependent Care FSA | General Purpose Healthcare and/or Dependent Care FSA | Limited Purpose Healthcare and/or Dependent Care FSA |
| You pay: | You pay: | You pay: | |
| Preventive Care Visit | Covered in full | Covered in full | Covered in full |
| Telemedicine | Covered in full | Covered in full | Covered in full |
| Primary Care Visit | $20 copay | $25 copay | 0% after deductible |
| Specialist Visit | $30 copay | $50 copay | 0% after deductible |
| Diagnostic Lab & X-ray | Covered in full | Covered in full | 0% after deductible |
| Urgent Care | $20 copay | $50 copay | 0% after deductible |
| Emergency Room (copay waived if admitted) | $150 copay | $200 copay | 0% after deductible |
| Inpatient/Outpatient Hospital Stay | $500 per admission | 20% after deductible | 0% after deductible |
| Bariatric Surgery Coverage | $500 per admission | 20% after deductible Require use of Anthem Blue Distinction Center |
0% after deductible Require use of Anthem Blue Distinction Center |
| Lantern (surgery care) | Not covered | 0% after deductible | 0% after deductible |
| Infertility Services | 50% | $20,000 lifetime max* | $20,000 lifetime max* |
| Prescription Drugs: Retail (up to a 30-day supply) | |||
| Generic | $15 copay | $10 copay | 0% after deductible |
| Brand Formulary** | $35 copay | $30 copay | |
| Non-Preferred Brand Formulary** | $35 copay | $60 copay | |
| Specialty/Self-Injectables | $35 copay | $0 copay when using PrudentRx*** | |
| Prescription Drugs: Mail Order (up to a 90-day supply) | |||
| Generic | $30 for up to 100-day supply | $25 copay | 0% after deductible |
| Brand Formulary** | $70 for up to 100-day supply | $75 copay | |
| Non-Preferred Brand Formulary** | $70 for up to 100-day supply (Must be approved through Formulary exception process) | $150 copay | |
| Specialty/Self-Injectables | Not covered | Not covered | Not covered |
*Includes coverage for IVF, GIFT and ZIFT.
**AmeriBen Blue & Green—review formulary exclusions at caremark.com or through our Member Services Department at 1.866.475.7589.
*** If you opt out of the PrudentRx program, a 30% coinsurance will apply. PrudentRx is available through the AmeriBen plans.
The California Kaiser medical plan will cover medically necessary bariatric surgeries. Contact Kaiser at 1.800.464.4000 for more information.
AmeriBen’s medical and pharmacy plans will cover medically necessary bariatric surgeries performed at an Anthem Blue Distinction Center and weight loss prescriptions with a prior authorization. When using a Distinction Center for bariatric surgery, the AmeriBen medical plan will provide assistance with travel and lodging costs.
AmeriBen members should reach out to medical management team to connect with a clinical team member who will assist you with pre-surgery requirements and will determine if you are a candidate for bariatric surgery.
To find out if you qualify, call 1.888.235.3813
If you’re 18 or older and enrolled in an IMA AmeriBen or California Kaiser medical plan, you have access to gender-affirming services as a benefit when they are medically necessary or when the services meet the criteria for surgery or treatment of gender-affirming care. Some services include medically necessary hormone therapy, preventive screenings, behavioral health assessments, sex reassignment surgery and referrals to culturally responsive community resources. In addition, the AmeriBen medical plan will provide up to a combined calendar year maximum of $2,000 in travel benefits for treatment of gender-affirming services.
The IMA AmeriBen Medical plan will cover the cost of a breast pump purchased 90 days prior to the birth or up to 12 months following delivery. In addition, the plan also covers breastfeeding support and counseling.
Kaiser members can contact member services at 1.800.464.4000 to get help requesting a breast pump. Also, expecting and new mothers will receive information on breastfeeding and requesting breast pumps by their Kaiser clinician staff. Additionally, Kaiser Permanente offers connected pregnancy services within the same organization, including pre-conception planning, prenatal care, prenatal testing, high-risk pregnancy support, labor and delivery care, routine newborn screening, lactation consultants, breastfeeding support, and postpartum care. To learn more, go to kp.org/breastfeeding or review the Maternity Flyer.
AmeriBen Engage Your All-in-One Healthcare App
AmeriBen Engage™ is designed to support you throughout your healthcare journey, making it easier than ever to manage your health benefits. With this enhanced member experience, you can:
Get started by downloading the app or visiting engage.ameriben.com. For assistance, contact the AmeriBen number in the contacts section.
To learn more, please review the flyer.
For information regarding your plan’s prescription coverage, please refer to the prescription drug coverage page.
Through Anthem, AmeriBen creates and publishes the Machine-Readable Files on behalf of IMA Financial Group, Inc. To link to the Machine-Readable Files, please click on the URL provided: https://www.anthem.com/machine-readable-file/search/
Lantern Care creates and publishes Machine-Readable Files on behalf of IMA Financial Group, Inc. To link to the Machine-Readable Files, please click on the URL provided: https://www.edhc.com/ProviderPricingTransparency/
