City of Vernon
Featured Plans and Rates - MAPD
Effective: January 01, 2027 through December 31, 2027
Medicare Advantage PPO 10PHD Medicare Advantage PPO 10PL Medicare Advantage PPO 10PH Custom 5/20/50/50 (E4) ECDHLP 5/15/25 (P3) ECDHLP 5/15/25 (E3) ECDHLP 52 52 52
$417.06 $387.21 $391.30
The quoted rates are subject to the attached Assumptions and Conditions. 290714003640
270710185973
Med Product ID:
Rx Product ID:
Pharmacy Plan
Medical Plan
Combined
Total Rate
(monthly billed PMPM)
Members
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City of Vernon Assumptions & Conditions Effective 01/01/2027 through 12/31/2027 Regulatory
Rates, rate guarantees, and benefits may need to be revised based on the effects of legislative, regulatory or other actions including, but not limited to, CMS guidance which affects the quoted product years. This includes, but is not limited to, additional CMS guidance in the Part D plan as part of the Inflation Reduction Act (IRA), as well as the CMS annual notice of Capitation Rates and Payment Policies, and any benchmark changes, risk score actions, and/or changes in payment methodologies, including those impacting any of the product lines or combination of product lines (MA/PDP/MAPD) offered.
Plan parameters and formularies are approved by CMS on an annual basis and can change in January each year. All Part D plan changes, such as deductibles, copays, Part D and Senior Rx Plus drug coverage, may only be implemented on the group’s original effective date and in January of each year thereafter.
This quote is contingent upon the majority (51%) of the enrolled membership residing in an adequate network service area. The service area and plan design are subject to CMS approval.
Product Offering
Enrolled members are entitled to Medicare Part A and enroll in Part B.
Eligibility for coverage for subscribers and/or their dependents is based on the subscriber and/or dependents meeting the group's requirements for coverage of retirees' medical benefits.
This quote assumes Anthem will be the exclusive post-65 retiree offering. Furthermore, the quote assumes that City of Vernon will offer a single Anthem plan design. Any additional plan selections will be subject to underwriting consideration and possible adjustments.
The group's eligibility policy does not allow for retirees to enroll in a group sponsored medical plan if the retiree has previously declined coverage.
Medical and prescription drug plans must be sold as a package.
Quote assumes Group will pay, on behalf of its members, any Late Enrollment Penalties (LEP) for applicable members. Should Group request Anthem to provide LEP billing directly to members, a premium adjustment may apply.
Operational
Contracted rates are on a Per-Member-Per-Month (PMPM) basis, with the total monthly charge determined by the number of enrolled members.
The group will contribute 50% of the premium. If the group's contribution varies from this amount, Anthem must be promptly notified and reserves the right to re-evaluate its underwriting position and potentially modify rates and rate guarantees.
Rates and rate guarantees assume the group/fund membership will not vary more than 10% from the quoted membership of 52 Medicare members.
Broker Commissions are excluded.
A minimum of 90-day implementation is required.
Anthem may retroactively modify the premium rates or adjust rates going forward if the data provided by City of Vernon or its representative is inaccurate or new data is submitted that varies from the data previously provided to Anthem by City of Vernon or its representative.
Plan change requests made within 45 days before either the effective date or the start of open enrollment may result in a rate adjustment.
Additional communications beyond those mandated by CMS or operationally required in accordance with Anthem standard processes, such as printed home mailers, may be subject to additional marketing communication charges to the group for development, fulfillment, and/or mailing.
This quote assumes co-branding (plan sponsor name and/ or logo is allowed on member materials including Medicare Advantage plan quality and health programs).
This proposal expires 60 days from the date of release or on the effective date, whichever is sooner.
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Medicare Advantage Plan Comparison for City of Vernon
Effective 1/1/2027
CityofVernon_2027_CA_PPOPlan10PH_0Ded
Covered Medical Benefits In Network Out of Network
Annual Medical Deductible $0 $0
Maximum Out-of-Pocket responsibility
(does not include prescription drugs) $3400 $3400
HighLevel Benefits
Inpatient Hospital Care $0 copay per admission $0 copay per admission Outpatient Surgery - (Outpatient Hospital
Facility or Ambulatory Surgical Center visit) $0 copay per visit $0 copay per visit Outpatient Surgery - Observation Room $0 copay per visit $0 copay per visit Physician Services - Primary Care Physician
(PCP) $10 copay per visit $10 copay per visit
Physician Services - Specialist $20 copay per visit $20 copay per visit Video Doctor Visits (LiveHealth Online) $0 copay for video doctor visits using livehealth online
LiveHealth Online (LHO)
$0 copay for video doctor visits
using livehealth online
LiveHealth Online (LHO)
Annual Wellness Visit $0 copay per visit $0 copay per visit Inpatient Services
Inpatient Services in a Psychiatric Hospital $0 copay per admission $0 copay per admission Skilled Nursing Facility (SNF) Care $0 copay for days
1-100 per benefit period
$0 copay for days
1-100 per benefit period
Home health agency care $0 copay per visit $0 copay per visit Hospice care (Part A and B services are
paid for by Original Medicare)
$20 copay for the one time
only consultation
1 visit per lifetime
$20 copay for the one time only
consultation
1 visit per lifetime
Outpatient Services
Chiropractic services $20 copay per visit $20 copay per visit Acupuncture for chronic low back pain $10 copay per visit $10 copay per visit Podiatry Services $10 copay per visit $10 copay per visit Outpatient Mental Health Care -
Professional Individual Therapy Visit $20 copay per visit $20 copay per visit Outpatient Mental Health Care -
Professional Group Therapy Visit $20 copay per visit $20 copay per visit Outpatient Mental Health Care -
Professional Partial Hospitalization Visit $20 copay per visit $20 copay per visit Ambulance $50 copay per one-way trip
for ambulance services
$50 copay per one-way trip for
ambulance services
Emergency care
$75 copay per visit
$75 copay is waived if the
member is admitted to the
hospital within 48 hours for
the same condition.
$75 copay per visit
$75 copay is waived if the
member is admitted to the
hospital within 48 hours for the
same condition.
Urgently Needed Services
$20 copay per visit
$20 copay is waived if the
member is admitted to the
hospital within 48 hours for
the same condition.
$20 copay per visit
$20 copay is waived if the
member is admitted to the
hospital within 48 hours for the
same condition.
Outpatient Rehabilitation Services -
Physical, Occupational & Speech Therapy
Visits $20 copay per visit $20 copay per visit
Cardiac rehabilitation services $0 copay per visit $0 copay per visit Pulmonary rehabilitation services $20 copay per visit $20 copay per visit Durable Medical Equipment and Related
Supplies 5% coinsurance per purchase 5% coinsurance per purchase Diabetes Self-management Training &
Supplies(If Purchased Through Pharmacy) -
Blood Glucose Test Strips, Lancet Devices,
Lancets & Glucose Control Solutions
$0 copay per purchase for
freestyle® (made by abbott)
and accu-chek® (made by
roche diagnostics)
$10 per purchase for all
other brands when
purchased through the
pharmacy
$0 copay per purchase for
freestyle® (made by abbott) and
accu-chek® (made by roche
diagnostics)
$10 per purchase for all other
brands when purchased through
the pharmacy
Diabetes Self-management Training &
Supplies(If Purchased Through a Pharmacy)
- Blood Glucose Monitor
$0 copay per purchase for
freestyle® (made by abbott)
and accu-chek® (made by
roche diagnostics)
$10 per purchase for all
other brands when
purchased through the
pharmacy
$0 copay per purchase for
freestyle® (made by abbott) and
accu-chek® (made by roche
diagnostics)
$10 per purchase for all other
brands when purchased through
the pharmacy
Diabetes self-management training &
supplies (If Purchased Through a DME
Provider) - Blood Glucose Test Strips,
Lancet Devices, Lancets & Glucose Control
Solutions
$0 copay per purchase $0 copay per purchase
Diabetes self-management training &
supplies (If Purchased Through a DME
Provider) - Blood Glucose Monitor $0 copay per purchase $0 copay per purchase Diabetes self-management training &
supplies - Therapeutic Shoes $0 copay per purchase $0 copay per purchase Diabetes self-management training &
supplies - Self-Management Training $0 copay per visit $0 copay per visit Outpatient Diagnostic Tests, Therapeutic
Services & Supplies - X-rays and Simple
Diagnostic Tests $20 copay per visit $20 copay per visit Outpatient Diagnostic Tests, Therapeutic
Services & Supplies - Complex Diagnostic
Tests and Radiology services $50 copay per visit $50 copay per visit Hearing services Medicare-covered
diagnostic hearing and balance evaluations $20 copay per visit $20 copay per visit Vision Care - Medicare Covered - Exams
(diagnose & treat diseases of the eye) -
Specialist $20 copay per visit $20 copay per visit
Vision Care - Medicare Covered -
Glasses/Contacts following Cataract
Surgery $20 copay per surgery $20 copay per surgery
Other Services
Prescription Drugs Covered Under Medical
Plan (Part B Drugs) - Medicare Covered
Part B Drug $20 copay for part b drugs $20 copay for part b drugs Additional supplemental benefits,
services, and discounts
Routine hearing services
$0 copay for routine hearing
exams
1 exam every calendar year
combined in-network and
out-of-network
$0 copay for hearing aid
fitting evaluations
1 evaluation per covered
hearing aid combined innetwork and out-of-network
$70 maximum benefit every
calendar year combined innetwork and out-of-network
$0 copay for hearing aids
$500 benefit per ear with a
$1000 maximum benefit
every three calendar years
Hearing Care Solutions
$0 copay for routine hearing
exams
1 exam every calendar year
combined in-network and out-ofnetwork
$0 copay for hearing aid fitting
evaluations
1 evaluation per covered hearing
aid combined in-network and
out-of-network
$70 maximum benefit every
calendar year combined innetwork and out-of-network
$0 copay for hearing aids through
hearing care solutions
$500 benefit per ear with a
$1000 maximum benefit every
three calendar years
Hearing Care Solutions
Routine vision services
$0 copay for routine vision
exams
1 exam every calendar year
combined in-network and
out-of-network
$0 copay for eyewear
$100 maximum benefit every
two calendar years combined
in-network and out-ofnetwork
$0 copay for non-elective
contact lenses
1 pair every two calendar
years combined in-network
and out-of-network
Blue View Vision
$70 reimbursement for routine
vision exams
1 exam every calendar year
combined in-network and out-ofnetwork
$100 reimbursement for
eyewear, maximum benefit every
two calendar years combined innetwork and out-of-network 100% reimbursement for nonelective contact lenses
1 pair every two calendar years
combined in-network and out-ofnetwork
Blue View Vision
Routine foot care
$10 copay per visit
12 visits per year combined
in-network and out-ofnetwork
$10 copay per visit
12 visits per year combined innetwork and out-of-network Health and Wellness Education Programs -
SilverSneakers
$0 copay for the
silversneakers fitness benefit
Tivity Health
Not Covered
24/7 NurseLine $0 copay for 24/7 nurseline $0 copay for 24/7 nurseline Foreign Travel - Emergency Outpatient
Care
$75 copay for emergency
care
$75 copay is waived if the
member is admitted to the
hospital within 48 hours for
the same condition.
$75 copay for emergency care
$75 copay is waived if the
member is admitted to the
hospital within 48 hours for the
same condition.
Foreign Travel - Urgently Needed Services
$20 copay for urgently
needed services
$20 copay is waived if the
member is admitted to the
hospital within 48 hours for
the same condition.
$20 copay for urgently needed
services
$20 copay is waived if the
member is admitted to the
hospital within 48 hours for the
same condition.
Foreign Travel - Inpatient Care $0 copay per admission
60 days per lifetime
$0 copay per admission
60 days per lifetime
Healthy Meals
$0 copay for healthy meals
14 meals per qualifying
event, allows up to four (4)
events each year (56 meals in
total).
GA Foods
Not Covered