Member Services ♦ Kern Legacy Classic Choice

Tuesday, March 19, 2019

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Kern Legacy Classic Choice Plan

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Kern County Health Benefits

Member Services ♦ Kern Legacy Classic Choice

Announcements

10/15/18		The POS Plan will now be known as Kern Legacy Classic Choice
12/23/15		Anthem Blue Cross Provider Search To search as a member, log in using your Username and Password or enter KEK (the first three characters of your POS Plan member ID number) in the "Identification number or alpha prefix" input area and press "continue".
2/13/2015		Anthem Data Breach

Member Overview
Medical Benefits
Prescription Benefits
Documents & Forms
Grievance/Appeals Procedure

Member Overview

Kern Legacy Classic Choice Employee Medical Plan is the County's oldest and most fully featured employee medical plan option. Kern Legacy Classic Choice uses the expansive Anthem network and is the only plan to include both in-network and out-of-network coverage. For those employees or dependents not residing in Kern County, Kern Legacy Classic Choice also offers statewide and nationwide coverage through the Anthem Blue Cross and Blue Cross/Blue Shield networks.

Plan administrators are:

Authorization Services: Clinix Healthcare
Claims Administration: HealthEdge Administrators
Provider Network: Anthem Blue Cross Provider Search Home Page
Pharmacy Benefits: WellDyneRx

Medical Benefits

Note: For information on dental and vision coverage, visit Kern County Health Benefits

Active Employee Benefits - Local (click to expand/hide)

Type of Plan/Benefit Level	In-Network	Out-of-Network
Who Directs Your Care	Contracted Primary Care Physician (PCP)	Member (some services require member to obtain prior authorization)
Who Provides Your Care	Providers contracted with this plan. Specialist visits require a referral or a Prior Authorization. Prior authorization must be obtained for services not available in the network.	Any licensed provider rendering covered services when referral/authorization was not obtained for In-Network benefits. When providers who are contracted on the national network are used as out-of-network providers, their fee discount reduces your out-of-pocket expenses.
Annual Deductible	$0	$200 per individual $400 per family (2 mbrs @ $200)
Calendar Year Out-of-Pocket Max (Once this maximum is paid by the member, the plan pays a higher amount - up to 100% coverage)	n/a: copay always applies	$2,000 per person $4,000 per family (2 mbrs @ $2000)
Primary Physician Visit	$15 copay	70% coverage R&C¹
Specialist Physician Visits	$25 copay	70% coverage R&C¹
Well Baby Care (up to age 2)	$0 copay	70% coverage R&C¹
Periodic Health Evaluations²	$0 copay	not covered
Outpatient Surgery / Procedure	$0 copay at Kern Medical or $100 copay	70% coverage R&C¹
Inpatient Hospitalization	$0 copay at Kern Medical or $150 copay per day, up to $750 yr max	70% coverage R&C¹
Emergency Room	$75 copay (waived if admitted)	$75 copay (waived if admitted)
Urgent Care	$15 copay	70% coverage R&C¹
Mammogram & Pap Smear	$0 copay	Not Covered
Immunizations (office visit copay may apply)	$0 copay	70% coverage R&C¹
Diagnostic Lab/X -Ray	$0 copay	70% coverage R&C¹
Physical, speech and occupational therapy	$0 copay (max. 60 visits/year combined)	70% coverage R&C¹ (max. 60 visits/year combined)
Durable Medical Equipment	$0 copay	70% coverage R&C¹
Allergy Testing & Diagnosis	$0 copay	70% coverage R&C¹
Chiropractic	$20 maximum benefit/visit (max. 30 visits per year)
Prescription	See Prescription Benefits

¹ After deductible has been met. R&C = Reasonable and Customary charges.

² Over 2 years old

This is a summary of the most-frequently-asked-about benefits. This chart does not explain benefits, out-of pocket maximums, exclusions, or limitations, nor does it list all benefits. For a complete explanation, please refer to the Summary Plan Description. (PDF)

Active Employee Benefits - Out of Area (OOA) (click to expand/hide)

Type of Plan/Benefit Level	Out-of-Area In-Network ** (Only available to members who reside outside Kern County or in designated areas)	Out-of-Network
Who Directs Your Care	Anthem Blue Cross and Blue Cross/Blue Shield providers	Member (some services require member to obtain prior authorization)
Who Provides Your Care	Anthem Blue Cross and Blue Cross/Blue Shield providers. Any licensed provider rendering covered services if directed by the Plan or an Anthem Blue Cross and Blue Cross/Blue Shield provider.	Any licensed provider rendering covered services when referral/authorization was not obtained for In-Network benefits. When providers who are contracted on the national network are used as out-of-network providers, their fee discount reduces your out-of-pocket expenses.
Annual Deductible	$0	$200 per individual $400 per family (2 mbrs @ $200)
Calendar Year Out-of-Pocket Max (Once this maximum is paid by the member, the plan pays a higher amount - up to 100% coverage)	n/a: copay always applies	$2,000 per person $4,000 per family (2 mbrs @ $2000)
Primary Physician Visit	$15 copay	70% coverage R&C¹
Specialist Physician Visits	$25 copay	70% coverage R&C¹
Well Baby Care (up to age 2)	$0 copay	70% coverage R&C¹
Periodic Health Evaluations²	$0 copay	not covered
Outpatient Surgery / Procedure	$100 copay	70% coverage R&C¹
Inpatient Hospitalization	$150 copay per day, up to $750 year max	70% coverage R&C¹
Emergency Room	$75 copay (waived if admitted)	$75 copay (waived if admitted)
Urgent Care	$15 copay	70% coverage R&C¹
Mammogram & Pap Smear	$0 copay	Not Covered
Immunizations (office visit copay may apply)	$0 copay	70% coverage R&C¹
Diagnostic Lab/X -Ray	$0 copay	70% coverage R&C¹
Physical, speech and occupational therapy	$0 copay (max. 60 visits/year combined)	70% coverage R&C¹ (max. 60 visits/year combined)
Durable Medical Equipment	$0 copay	70% coverage R&C¹
Allergy Testing & Diagnosis	$0 copay	70% coverage R&C¹
Chiropractic	$20 maximum benefit/visit (max. 30 visits per year)
Prescription	See Prescription Benefits

¹ After deductible has been met. R&C = Reasonable and Customary charges.

² Over 2 years old

**Out of Area Plan enrollment is limited to POS plan members who reside outside of Kern County or in Frazier Park, Pine Mountain, Lebec, Lake of the Woods, Pinon Pines, Tejon, Mojave, Rosamond, Boron, Edwards, Willow Springs, Desert Lake or California City. With Out-of-Area enrollment, the member directs care instead of care being directed by a Kern County PCP. In-network benefits are obtained by using contracted providers on the national network or as directed by the plan administrator.

Retiree Benefits - Local (click to expand/hide)

Type of Plan/Benefit Level	In-Network	Out-of-Network
Who Directs Your Care	Contracted Primary Care Physician (PCP)	Member (some services require member to obtain prior authorization)
Who Provides Your Care	Providers contracted with this plan. Specialist visits require a referral or a Prior Authorization. Prior authorization must be obtained for services not available in the network.	Any licensed provider rendering covered services when referral/authorization was not obtained for In-Network benefits. When providers who are contracted on the national network are used as out-of-network providers, their fee discount reduces your out-of-pocket expenses.
Annual Deductible	$0	$200 per individual $400 per family (2 mbrs @ $200)
Calendar Year Out-of-Pocket Max (Once this maximum is paid by the member, the plan pays a higher amount - up to 100% coverage)	n/a: copay always applies	$2,000 per person $4,000 per family (2 mbrs @ $2000)
Primary Physician Visit	$15 copay	70% coverage R&C¹
Specialist Physician Visits	$25 copay	70% coverage R&C¹
Well Baby Care (up to age 2)	$15 copay	70% coverage R&C¹
Periodic Health Evaluations²	$15 copay	not covered
Prostate Exams and Mammograms	$0 copay	Not Covered
Outpatient Surgery / Procedure	$0 copay at Kern Medical or $100 copay	70% coverage R&C¹
Inpatient Hospitalization	$0 copay at Kern Medical or $150 copay per day, up to $750 yr max	70% coverage R&C¹
Emergency Room	$75 copay (waived if admitted)	$75 copay (waived if admitted)
Urgent Care	$15 copay	70% coverage R&C¹
Immunizations (office visit copay may apply)	$0 copay	70% coverage R&C¹
Diagnostic Lab/X -Ray	$0 copay	70% coverage R&C¹
Physical, speech and occupational therapy	$0 copay (max. 60 visits/year combined)	70% coverage R&C¹ (max. 60 visits/year combined)
Durable Medical Equipment	$0 copay	70% coverage R&C¹
Allergy Testing & Diagnosis	$0 copay	70% coverage R&C¹
Chiropractic	$20 maximum benefit/visit (max. 30 visits per year)
Prescription	See Prescription Benefits

¹ After deductible has been met. R&C = Reasonable and Customary charges.

² Over 2 years old

Retiree Benefits - Out of Area (OOA) (click to expand/hide)

Type of Plan/Benefit Level	Out-of-Area In-Network ** (Only available to members who reside outside Kern County or in designated areas)	Out-of-Network
Who Directs Your Care	Anthem Blue Cross and Blue Cross/Blue Shield providers	Member (some services require member to obtain prior authorization)
Who Provides Your Care	Anthem Blue Cross and Blue Cross/Blue Shield providers. Any licensed provider rendering covered services if directed by the Plan or an Anthem Blue Cross and Blue Cross/Blue Shield provider.	Any licensed provider rendering covered services when referral/authorization was not obtained for In-Network benefits. When providers who are contracted on the national network are used as out-of-network providers, their fee discount reduces your out-of-pocket expenses.
Annual Deductible	$0	$200 per individual $400 per family (2 mbrs @ $200)
Calendar Year Out-of-Pocket Max (Once this maximum is paid by the member, the plan pays a higher amount - up to 100% coverage)	n/a: copay always applies	$2,000 per person $4,000 per family (2 mbrs @ $2000)
Primary Physician Visit	$15 copay	70% coverage R&C¹
Specialist Physician Visits	$25 copay	70% coverage R&C¹
Well Baby Care (up to age 2)	$15 copay	70% coverage R&C¹
Periodic Health Evaluations²	$15 copay	not covered
Prostate Exams and Mammograms	$0 copay	70% coverage R&C¹
Outpatient Surgery / Procedure	$100 copay	70% coverage R&C¹
Inpatient Hospitalization	$150 copay per day, up to $750 year max	70% coverage R&C¹
Emergency Room	$75 copay (waived if admitted)	$75 copay (waived if admitted)
Urgent Care	$15 copay	70% coverage R&C¹
Immunizations (office visit copay may apply)	$0 copay	70% coverage R&C¹
Diagnostic Lab/X -Ray	$0 copay	70% coverage R&C¹
Physical, speech and occupational therapy	$0 copay (max. 60 visits/year combined)	70% coverage R&C¹ (max. 60 visits/year combined)
Durable Medical Equipment	$0 copay	70% coverage R&C¹
Allergy Testing & Diagnosis	$0 copay	70% coverage R&C¹
Chiropractic	$20 maximum benefit/visit (max. 30 visits per year)
Prescription	See Prescription Benefits

¹ After deductible has been met. R&C = Reasonable and Customary charges.

² Over 2 years old

Prescription Benefits

Overview

Prescription benefits for Kern Legacy Classic Choice are administered by WellDyneRx.

WellDyneRx Website

2018 WellDyneRx Universal Formulary (PDF)

A list of the most commonly-prescribed drugs covered by the Plan

Specialty medications (previously provided by Briova) will be provided by US Specialty Care.

US Specialty Care Website

The POS prescription benefit includes generic, brand-name, and specialty medications. POS members can fill their prescriptions at Kern Medical pharmacies at reduced copays for generic and preferred name-brand medications and, through the POS Plan’s Over-the-Counter (OTC) prescription benefit, you can also receive some OTC non-sedating antihistamines (NSA) and Proton Pump Inhibitor (PPI) medications for $0 copay with a physician’s prescription.

Mail Order/Home Delivery Program

Mail Order Frequently Asked Questions

Mail Order Registration and New Prescription Order Form (PDF)

Mail Order Specialty Prescription Form (PDF)

Copays

POS Prescription Benefit copays - Active Employees
Prescription - Retail	30-day supply at WellDyneRx-affiliated pharmacy: $5 Generic ($0 at Kern Medical Pharmacies) $15 Preferred Name-Brand * $30 Non-Preferred Name-Brand *
Prescription - Mail order	90-day supply through WellDyneRx Home Delivery: $10 Generic $30 Preferred Name-Brand * $60 Non-Preferred Name-Brand *

POS Prescription Benefit copays - Retirees
Prescription - Retail	30-day supply at WellDyneRx-affiliated pharmacy: $5 Generic ($0 at Kern Medical Pharmacies) $25 Preferred Name-Brand * $40 Non-Preferred Name-Brand *
Prescription - Mail order	90-day supply through WellDyneRx Home Delivery: $10 Generic $50 Preferred Name-Brand * $80 Non-Preferred Name-Brand *