HEALTH MAINTENANCE ORGANIZATION (HMO) BENEFITS
Effective January 1, 2008 through December 31, 2008

The following is a summary of the standardized HMO benefits. It is intended to help you choose a health plan. This summary provides
only a general overview. Refer to each plan’s Evidence of Coverage (EOC) booklet for exact terms and conditions of coverage.

BENEFITS DESCRIPTION	STANDARDIZED HMO COPAYMENTS
Physician Services
Office Visits	$15
Periodic Health Exam/Preventative Care (annual Health Exam)	No Charge
Pregnancy & Maternity Care	No Charge
Well Baby Care	No Charge
Immunization/Inoculation	No Charge
Allergy Testing	No Charge – Blue Shield HMO’s Kaiser - $15
Allergy Treatment	No Charge
Hearing Exam Testing	No Charge
Gynecological Exam	No Charge
Inpatient Hospital Visits	No Charge
Vision Exam (Refraction)	No Charge – Blue Shield HMO’s Kaiser - $15
Surgery/Anesthesia	No Charge – Blue Shield HMO’s Kaiser – No Charge for inpatient; $15 for outpatient
Urgent Care Visits	$15
Hospitalization
Inpatient	No Charge
Outpatient	No Charge – Blue Shield HMO’s Kaiser - $15 (outpatient surgery)
Diagnostic X-Ray/Lab
(Kaiser - some procedures may require a co-pay	No Charge
Prescription Drugs
Up to a 30-day supply of drugs for short-term or acute illness Mail Order Program. 90 day supply for drugs which are taken over long periods of time (maintenance drugs).	$5 generic, $15 brand-name, $45 non-formulary drug prescription (Blue Shield Only) $10 generic, $25 brand name, $75 non-formulary drug prescription
Emergency Services
(Co-payment waived if admitted)	$50/visit
Ambulance
See coverage booklets for details	No Charge
Mental Health
Inpatient- Treatment of an acute phase of mental health condition during a certified confinement in a participating hospital.	No Charge- up to 30 days per calendar year
Outpatient- Evaluation, crisis intervention, and treatment for conditions, which are subject to significant improvement through relatively short-term therapy.	$20/visit- up to 20 visits per calendar year
Substance Abuse
Inpatient-Hospitalization as medically necessary to remove toxic substances from the system.	No Charge
Outpatient- Evalutaion, crisis intervention, and treatment for conditions which are subject to significant improvement through relatively short-term thearpy.	Blue Shield plans - $15/visit Kaiser - $15 individual; $5 group therapy
Chiropractic
Not covered by Blue Shield HMO’s.	Kaiser $10 (20 visits per calendar year)

This is only a brief summary. You should carefully review the plan’s Evidence of Coverage booklet for more details on these benefits. 
Booklets are available in the Human Resources Department.