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Medical Plans

SCU offers five medical plan options, allowing you to choose the plan that’s best for you and your family. A brief description of each plan is included below.

If you opt to waive medical coverage, Santa Clara University offers an incentive payment of $150 per month. You must fill out the Health Credit Waiver Form and provide proof of coverage through another plan. 

  

Kaiser
HMO: (800) 464-4000

 

Kaiser HMO Options

PLAN HIGHLIGHTS

Kaiser HMO SILVER Plan (Northern Ca Only)

Kaiser HMO GOLD Plan (Northern Ca Only)

Kaiser Providers
& Facilities

Kaiser Providers
and Facilities

Plan Description

All your healthcare services must be received from Kaiser providers and facilities.

All your healthcare services must be received from Kaiser providers and facilities.

Annual Deductible

None

None

Annual Maximum Out-of-pocket (1)

 

 

Individual

$3,000

$1,500

Family

$6,000

$3,000

Lifetime Maximum Benefit

Unlimited

Unlimited

Physician Services

 

 

Doctor Office Visits / Specialist Visit

$30 Copay / $30 Copay

$20 Copay / $20 Copay

Routine Physical Exam /
Preventive Care

No Copay

No Copay

Diagnostic X-ray / Lab.

$10 Copay

Covered at 100%

Chiropractic Care

$15 Copay; Limited to 30 Visits per Calendar Year

$15 Copay; Limited to 30 Visits per Calendar Year

Optical Dispensing

$175 Eyewear Allowance Every 2 Years

$175 Eyewear Allowance Every 2 Years

Prescription Drugs

 

Tier 1 (30-day supply)

$10 copay

$10 copay

Tier 2 (30-day supply)

$30 copay

$25 copay

Tier 3 (30-day supply)

 

 

Tier 4 (30-day supply)

 

 

Mail Order (90-day supply)

2 x copay (100-day supply)

2 x copay (100-day supply)

Hospital Services

 

 

Room & Board

$500 Copay per Day

$250 Copay per Admission

Maternity (delivery)

Same as Other Illness

Same as other Illness

Emergency Room (waived if admitted)

$150 Copay

$50 Copay

Mental Health / Chemical Dependency

 

 

Inpatient

$500 Copay per Day

$250 per Admission

Outpatient

$30 Copay per Visit

$20 Copay per Visit

(1)         Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using an out-of-network provider

Blue Cross
HMO: (800) 888-8288
HDHP/PPO: (866) 207-9878

 

 

  

Blue Cross HMO Options

PLAN HIGHLIGHTS

Blue Cross SILVER HMO Plan
(Ca Only)

Blue Cross GOLD HMO Plan
(Ca Only)

 

IN-NETWORK

IN-NETWORK

 

Plan Description

You choose a Primary Care Physician to coordinate all of your healthcare. Services obtained from non-authorized providers will not be covered by Blue Cross.

You choose a Primary Care Physician to coordinate all of your healthcare. Services obtained from non-authorized providers will not be covered by Blue Cross.

 

Annual Deductible

None

None

 

Annual Maximum Out-of-pocket (1)

 

 

 

Individual

$3,500

$2,000

 

Family

$7,000

$4,000

 

Lifetime Maximum Benefit

Unlimited

Unlimited

 

Physician Services

 

 

 

Doctor Office Visits / Specialist Visit

$30 Copay / $45 Copay

$20 Copay / $40 Copay

 

Routine Physical Exam /
Preventive Care

No Copay

No Copay

 

Diagnostic X-ray / Lab

Covered at 100%

Covered at 100%

 

Chiropractic Services

$15 Copay (Chiropractor or Acupuncturist) Limited to 20 combined visits per calendar year

$15 Copay (Chiropractor or Acupuncturist) Limited to 20 combined visits per calendar year

 

Optical Dispensing

Blue View Vision (if elected) Exam: every 12 month;

Contact Lenses or Glasses: every 24 months

Blue View Vision (if elected) Exam: every 12 month;

Contact Lenses or Glasses: every 24 months

 

Prescription Drugs

 

 

Tier 1 (30-day supply)

$10 Copay

$10 Copay

 

Tier 2 (30-day supply)

$25 Copay

$25 Copay

 

Tier 3 (30-day supply)

$50 Copay

$50 Copay

 

Tier 4 (30-day supply)

20% to $250 Copay

20% to $250 Copay

 

Mail Order (90-day supply)

Tier 1:  2.5 x Copay
Tier 2 & 3:  3 x Copay

Tier 4:  20% to $250 Copay (30-day supply)

Tier 1:  2.5 x Copay
Tier 2 & 3:  3 x Copay

Tier 4:  20% to $250 Copay  (30-day supply)

 

Hospital Services

 

 

Room & Board

$1,000 Copay per Day
up to 3 Days Max.

$250 Copay per Admission

 

Maternity (delivery)

Same as Other Illness

Same as other Illness

 

Emergency Room (waived if admitted)

$150 Copay

$100 Copay

 

Mental Health / Chemical Dependency

 

 

Inpatient

$1,000 Copay per Day
up to 3 Days Max.

$250 per Admission

 

Outpatient

$30 Copay per Visit
(pre-service review required)

$20 Copay per Visit
(pre-service review required)

 

(1)         Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using an out-of-network provider

  

Blue Cross Lumenos HSA PPO Plan

PLAN HIGHLIGHTS

Blue Cross LUMENOS
HEALTH SAVINGS ACCOUNT (HSA) (1)

PPO (2)

OUT-OF-NETWORK (2)

Plan Description

This Lumenos plan allows an insured person to use a Health Savings Account to pay for routine medical care. The program also includes traditional health coverage, similar to a typical health plan that protects the insured person against large medical expenses.

Annual Deductible

 

 

Individual

$2,000

$4,000

Family

$4,000

$8,000

Annual Maximum Out-of-pocket (includes deductible) (3)

 

 

Individual

$3,425

$12,000

Family

$6,850

$24,000

Lifetime Maximum Benefit

Unlimited

Physician Services

 

 

Doctor Office Visits

Covered at 90%

Covered at 70%

Routine Physical Exam /
Preventive Care

Covered at 100%
(deductible waived)

Covered at 70%

Diagnostic X-ray / Lab.

Covered at 90%

Covered at 70%

Physical Therapy / Chiropractic Care

Covered at 90%; Limited to
30 Visits per Calendar Year

Covered at 70%; Limited to
30 Visits per Year

Prescription Drugs (after deductible is met)

 

Tier 1 (30-day supply)

$10 Copay

Covered at 70%

Tier 2 (30-day supply)

$40 Copay

Covered at 70%

Tier 3 (30-day supply)

$60 Copay

Covered at 70%

Tier 4 (30-day supply)

30% to $250 Copay

Covered at 70%

Mail Order (90-day supply)

Tier 1:  2.5 x Copay
Tier 2 & 3:  3 x Copay

Tier 4:  30% to $250 Copay

Not Covered

Hospital Services

 

 

Room & Board

Covered at 90%

Covered at 70% limited to $1,000 per day for non-emergency admission

Maternity (delivery)

Covered at 90%

Covered at 70% limited to $1,000 per day for non-emergency admission

Emergency Room

Covered at 90%

Covered at 90%

Mental Health / Chemical Dependency

 

Inpatient

Covered at 90%

Covered at 70% limited to $1,000 per day for non-emergency admission

Outpatient

Covered at 90%

Covered at 70% limited to $350 per visit

(1)     Employees enrolling in the HSA (compatible) High Deductible PPO plan are eligible to establish and contribute to a Health Savings Account (HSA). More can be learned about HSAs by contacting Blue Cross 

(2)     PPO network reimbursement based on negotiated fees, Non-PPO network reimbursement based on reasonable & customary fees

(3)         Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using an out-of-network provider

Health Savings Account

Those electing the HSA (compatible) Blue Shield High Deductible PPO Plan are eligible to establish and contribute to a Health Savings Account. HSA’s are tax-advantaged accounts that can be used to pay for certain eligible medical expenses. For the 2019 Benefit Year, those electing Individual Coverage can contribute up to $3,500, and those electing Family Coverage can contribute up to $7,000 on a pre-tax basis into an HSA.  Those over age 55 can contribute more (an additional $1,000).

HSA Overview

Administered by an authorized financial institution and working in conjunction with a High Deductible Health Plan (HDHP), a Health Savings Account (HSA) allows you to put money aside and reimburse yourself for medical expenses on a tax-deductible basis. Unspent funds accumulate tax-free and roll over from year-to-year (no “use it or lose it” rule). Additionally, distributions are tax-free for qualified expenses and because you own the HSA, the monies in the account will remain with you if you leave the company or the work force. In most states, money accumulates with tax-free interest until retirement. And as long as you are enrolled in a compatible HDHP, you can continue to contribute to your HSA until you reach age 65.

Advantages of an HSA

HSAs encourage consumers to purchase health care wisely, simply for the reason that you are utilizing personal funds to pay health-related expenses. Although an HSA comes with this responsibility, HDHP with an HSA may also lend several advantages including:

  • Lower costs than traditional PPO medical plans
  • Reduced taxable income and tax-free withdrawals when paying for qualified expenses
  • A vehicle to save for future health needs, such as long term care premiums or health care after retirement

Qualifying for an HSA

The IRS has set guidelines regarding who qualifies for an HSA. An individual is considered eligible if:

  • You are covered under a qualified HDHP
  • You do not have qualified health insurance outside of your HDHP
  • You are not enrolled in Medicare
  • You are not claimed as a dependent on someone else’s tax return
  • You are not enrolled in a general Health Care FSA

2019 Medical Plan Comparisons:

2019 MEDICAL PLANS 

Kaiser

HMO

Blue Shield

Trio Network

HMO

Blue Shield

Access+ Network

HMO

Blue Shield

HDHP PPO HSA

PPO/Non-PPO

Annual Deductible        
Individual None None None $2,000 / $4,000
Individual with Dependent(s) None None None $2,700 / $5,200
Family None None None $4,000 / $8,000
Annual Out of Pocket Maximum        
Individual & Individual with Dependent(s) $1,500 $2,000 $2,000 $3,425 / $12,000
Family $3,000 $4,000 $4,000 $6,850 / $24,000

Medical Services

Primary Care Visit $20 copay $20 copay $20 copay 90% / 70%
Specialist Office Visit $20 copay $20 copay $40 copay
$20 with PCP referral
90% / 70%
Basic X-ray and Laboratory No charge No charge No charge 90% / 70%
Inpatient Hospital $250 copay per admission $250 copay per admission $250 copay per admission 90% / 70%
Emergency Room $50 copay $100 copay $100 copay 90% / 90%
Urgent Care $20 copay $20 copay $20 copay 90% / 70%
Chiropractic $15 copay per visit to
30 visits per year
$15 copay per visit to
20 visits per year
$15 copay per visit to
20 visits per year
90% / 70%
Hearing Aid $2,500 per device, 2 devices every 3 years $2,000 every 2 years $2,000 every 2 years 80% / 80%
Prescription Drugs       After Deductible
Generic / Tier 1 $10 copay $10 copay $10 copay $10 copay / $10+25%
Formulary / Tier 2 $25 copay $25 copay $25 copay $40 copay / $40+25%
Non-Formulary / Tier 3 $25 copay $50 copay $50 copay $60 copay / $60+25%
Monthly Employee Contribution    
Employee Only $51.32 $11.12 $77.81 $113.92
Employee + 1 $301.63 $152.20 $351.93 $421.64
Employee + Family $455.80 $290.94 $536.13 $677.60
  2018 2019
 MEDICAL PLANS Anthem Blue Cross
HMO
Gold Plan
Blue Shield
HMO
Trio Network
Blue Shield
HMO
Access+ Network
Deductible - Individual / Family None None None
Out of Pocket Maximum - Individual / Family $2,000 / $4,000 $2,000 / $4,000 $2,000 / $4,000
Medical Services      
Primary Care Visit $20 copay $20 copay $20 copay
Specialist Office Visit $40 copay $20 copay $40 copay
$20 copay with PCP referral
Basic X-ray and Laboratory No copay No copay No copay
Inpatient Hospital $250 copay per admit $250 copay per admit $250 copay per admit
Emergency Room (copay waived if admitted) $100 copay $100 copay $100 copay
Urgent Care $20 copay $20 copay $20 copay
Chiropractic $15 copay per visit to 20 visits per year $15 copay per visit to 20 visits per year $15 copay per visit to 20 visits per year
Hearing Aid 80% $2,000 every 2 years $2,000 every 2 years
Prescription Drugs      
Generic / Tier 1 $10 $10 $10
Formulary / Tier 2 $25 $25 $25
Non-Formulary / Tier 3 $50 $50 $50
Specialty / Tier 4 20% up to $250 per prescription 20% up to $200 per prescription 20% up to $200 per prescription
  2018 2019
 MEDICAL PLANS Anthem Blue Cross
High Deductible PPO HSA
Blue Shield
High Deductible PPO HSA
  PPO Non-PPO PPO Non-PPO
  Member pays Member pays
Annual Deductible      
Individual $2,000 $4,000 $2,000 $4,000
Individual with Dependent(s) $2,700 $5,200 $2,700 $5,200
Family $4,000 $8,000 $4,000 $8,000
Out of Pocket Maximum      
Individual & Individual with Dependent(s) $3,425 $12,000 $3,425 $12,000
Family $6,850 $24,000 $6,850 $24,000
Medical Services    
Primary Care Visit 10% 30% 10% 30%
Specialist Office Visit 10% 30% 10% 30%
Basic X-ray and Laboratory 10% 30% 10% 30%
Inpatient Hospital 10% 30% 10% 30%
Emergency Room (copay waived if admitted) 10% 10% 10% 10%
Urgent Care 10% 30% 10% 30%
Chiropractic 10% 30% 10% 30%
Hearing Aid 20% 20% 20% 20%
Prescription Drugs    
Generic / Tier 1 $10 copay 30% up to $250 per prescription $10 copay $10 + 25%
Formulary / Tier 2 $40 copay 30% up to $250 per prescription $40 copay $40 + 25%
Non-Formulary / Tier 3 $60 copay 30% up to $250 per prescription $60 copay $60 + 25%
Specialty / Tier 4 30% up to $250 per prescription 30% up to $250 per prescription 30% up to $200 per prescription Not covered