ZapIndex

Prepared for Fountain of LoveZip code 91768Eff date 5/2020

Plan

Bronze 60 HDHP 6900/0 (shop)

Bronze 60 HMO 6300/65 (shop)

Bronze 60 HDHP EPO 6900/0 (shop)

EnhancedCare Bronze 60 HDHP PPO 5600/20% + Child Dental Alt (shop)

Silver 70 HDHP HMO 2500/20 (shop)

Silver 70 EPO 1500/50 (shop)

Silver 70 HMO 1800/55 (shop)

Trio Silver 70 HMO 2250/50 Plus Child Dental (shop)

Silver 70 HMO 1650/55 (shop)

Silver 70 HMO 2250/50 (shop)

Bronze 60 HDHP PPO 5600/20% + Child Dental Alt (shop)

Silver 70 EPO 2250/50 (shop)

Bronze 60 PPO 6300/65 + Child Dental (shop)

Trio Gold 80 HMO 250/25 w Child Dental (shop)

Gold 80 EPO 0/30 (shop)

Gold 80 HMO 500/30 (shop)

Gold 80 EPO 250/25 (shop)

Gold 80 HMO 250/25 (shop)

Trio Platinum 90 HMO 0/15 w Child Dental (shop)

Silver 70 Value PPO 1700/50 + Child Dental Alt (shop)

Silver 70 HDHP PPO 1400/40% + Child Dental Alt (shop)

Platinum 90 HMO 0/15 (shop)

Gold 80 Value PPO 750/15 + Child Dental Alt (shop)

Platinum 90 HMO 0/10 (shop)

Platinum 90 EPO 0/15 (shop)

Gold 80 PPO 0/30 + Child Dental Alt (shop)

Silver 70 PPO 2250/50 + Child Dental (shop)

Platinum 90 PPO 0/15 + Child Dental (shop)

Metal

Bronze

Silver

Bronze

Silver

Bronze

Gold

Platinum

Silver

Platinum

Gold

Platinum

Gold

Silver

Platinum

Network

Kaiser Permanente

Oscar EPO

EnhancedCare PPO

Kaiser Permanente

Oscar EPO

Kaiser Permanente

Trio ACO Network

Kaiser Permanente

Full PPO

Oscar EPO

Full PPO

Trio ACO Network

Oscar EPO

Kaiser Permanente

Oscar EPO

Kaiser Permanente

Trio ACO Network

Full PPO

Kaiser Permanente

Full PPO

Kaiser Permanente

Oscar EPO

Full PPO

Deductible

$6900/$13,800 family

$6300/$12,600 family

$6900/$13,800 family

$5600/$11,200 family

$2500 (fam cov $2800 ind or $5000 fam)

$1500/$3000 family

$1800/$3600 family

$2250/$4500 family

$1650/$3300 family

$2250/$4500 family

$5600/$11,200 family

$2250/$4500 family

$6300/$12,600 family

$250/$500 family

None

$500 ($1000 family)

$250 ($500 family)

None

$1700/$3400 family

$1400/$2800 family

None

$750/$1500 family

None

$2250/$4500 famly

None

Coinsurance

100% coverage for most services

60% coverage for most services

100% coverage (after ded)

80% coverage for most services

Fixed copayments for most services

55% coverage for most services

80% coverage for most services

60% coverage for most services

80% coverage for most services

Fixed copayments for most services

60% coverage for most services

Fixed copays for most services

70% coverage for most services

Fixed copays for most services

Fixed copayments for most services

Fixed copays for most services

60% coverage for most services

Fixed copays for most services

70% coverage for most services

Fixed copays for most services

Fixed copayments for most services

70% coverage for most services

80% coverage for most services

90% coverage for most services

Out of Pocket Mzx

$6900/$13,800 family

$7800/15,600 family

$6900 ($13,800 family)

$6850/$13,700 family

$6850/13,700 family

$8150 ($16,300 fam)

$7800/15,600 family

$7800/$15,600 family

$7800/15,600 family

$6850/$13,700 family

$7800 ($15,600 fam)

$7800/$15,600 family

$6000 ($12,000 family)

$7000/14,000 family

$7800 ($15,600 fam)

$7800/15,600 family

$4500/9000 family

$7800/$15,600 family

$6850/$13,700 family

$4500/$9000 family

$7600/$15,200 failily

$3000/$6000 family

$4500 ($9000 family)

$7400/$14,800 family

$7800/$15,600 family

$4500/$9000 family

Ambulance

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

Covered benefit

55% coverage (after deductible)

$250 copayment (after deductible)

60% coverage (after ded)

$250 (after deductible)

80% coverage (ded applies)

Covered benefit

60% coverage (ded applies)

$250 copayment

Covered benefit

$250 copayment (after ded)

Covered benefit

$250 copayment (after ded)

$150 copayment

60% coverage (ded applies)

$150 copayment

$250 copayment (ded applies)

$150 copayment

Covered benefit

70% coverage

$250 copayment (ded applies)

$150 copaymet

Chiropractor

Not covered

Optional

Not covered

Optional

Not covered

Optional

Not covered

Optional

Not covered

Optional

Not covered

Optional

Durable Med Equip

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

Covered benefit

55% coverage (after deductible)

80% coverage

60% coverage (after ded)

80% coverage (ded applies)

Covered benefit

60% coverage (ded applies)

80% coverage

Covered benefit

80% coverage

Covered benefit

80% coverage (after ded)

90% coverage

60% coverage (ded applies)

90% coverage

70% coverage (ded applies)

90% coverage

Covered benefit

70% coverage

80% coverage (ded waived)

90% coverage

Emergency Room

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

$750 copayment

55% coverage (after deductible)

$400 copay (after ded)

60% coverage (after ded)

$250 copay after ded

80% coverage (ded applies)

$400 copay (after deductible)

60% coverage (ded applies)

$250 copayment

$350 copayment

$250 copayment (after ded)

$250 copay after ded

$250 copayment (after ded)

$150 copayment

60% coverage (ded applies)

$150 copay

$250 copayment (ded applies)

$200 copay

$150 copayment

70% coverage

$400 copayment (ded applies)

$150 copayment

Hospital

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

50% coverage (after ded)

55% coverage (after deductible)

80% coverage (after deductible)

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

80% cov (after deductible)

60% coverage (ded applies)

$600 per day 1st 5 days

70% coverage

$600 per day per admit ($3000 max)

$300 or $600 copay (1st 5 days)

$600 per day per admit ($3000 max)

$250 per day 1st 5 days

60% coverage (ded applies)

$150 copay

70% coverage (ded applies)

$500 per admission

$100 or $250 copay (1st 5 days)

70% coverage

80% coverage (ded applies)

90% coverage

Infertility

Optional

Not covered

Optional

Not covered

Optional

Not covered

Optional

Lab & X-Ray

100% coverage (after deductible)

Lab $40/X-ray 60% coverage (after ded)

100% coverage (after ded)

Lab: 80% coverage (ded applies)/X-ray 80% cov (ded applies)

80% coverage (ded applies)

Lab: $75 copay/X-ray: $75 copay

rabaLy $25 after ded/X-ray $55 after ded

$40 lab/$85 X-ray

$25 lab/$75 X-ray after ded

$40 lab/$85 X-ray

Lab: 80% coverage (ded applies)/X-ray 80% cov (ded applies)

Lab: $40 copay/X-ray: $85 copay

Lab: $40 copay (ded waived)/X-ray 60% cov (ded applies)

$25 lab/$65 X-ray

$50 lab/$50 X-ray

$20 lab/$40 X-ray

$25 lab/$65 X-ray

Lab $15 copay / X-ray $30 copay

Lab: $40 copay (ded applies)/X-ray $50 copay(ded applies)

Lab: 60% coverage (ded applies)/X-ray 60% cov (ded applies)

$15 lab/$30 X-ray

Lab: $25 copay (ded applies)/X-ray $25 copay(ded applies)

$20 lab/$40 X-ray

$15 lab/$30 X-ray

Lab: $30 copay/X-ray $40 copay

Lab: $40 copay (ded waived)/X-ray $85 copay (ded waived)

Lab: $15 copay/X-ray $30 copay

Office Visit

100% coverage (after deductible)

$65 copayment first 3 visits then deductible applies

100% coverage (after ded)

80% coverage (ded applies)

$50 copayment

$55 copayment

$50 copayment

$55 copayment

$50 copayment

80% coverage (ded applies)

$50 copayment

$65 copay 1st 3 visits then ded applies

$25 copayment

$30 copayment

$25 copayment

$15 copayment

$50 copayment

60% coverage (ded applies)

$15 copayment

$10 copayment

$15 copayment

$30 copayment

$50 copayment

$15 copayment

Specialist

100% coverage (after deductible)

$95 copayment first 3 visits then deductible applies

100% coverage (after ded)

80% coverage (ded applies)

$75 copayment

$85 copayment

$80 copayment

$85 copayment

80% coverage (ded applies)

$85 copayment

$95 copay 1st 3 visits then ded applies

$65 copayment

$50 copayment

$35 copayment

$50 copayment

$30 copayment

$75 copayment

60% coverage (ded applies)

$30 copayment

$20 copayment

$30 copayment

$50 copayment

$85 copayment

$30 copayment

Outpatient Surgery

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

Covered benefit

55% coverage (after deductible)

80% coverage (after deductible)

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

Covered benefit

60% coverage (ded applies)

$300 copayment

Covered benefit

$600 copayment (per procedure)

Covered benefit

$34 copayment (per procedure)

$100 copayment

60% coverage (ded applies)

$125 copayment (per procedure)

70% coverage (ded applies)

$300 copayment (per procedure)

Covered benefit

70% coverage

80% coverage (ded waived)

90% coverage

Physical Therapy

100% coverage (after deductible)

$65 copayment

100% coverage (after ded)

80% coverage

80% coverage (ded applies)

Covered benefit

$65 copayment

$50 copayment (after deductible)

$65 copayment

$50 copayment

80% coverage

Covered benefit

$65 copayment

$25 copayment

Covered benefit

$30 copayment

Covered benefit

$25 copayment

$15 copayment

$50 copayment

60% coverage

$15 copayment

$50 copayment

$10 copayment

Covered benefit

$30 copayment

$50 copayment

$15 copayment

Inpatient Psych

100% coverage (after deductible)

60% coverage (after ded)

100% coverage (after ded)

80% coverage (ded applies)

50% coverage (after ded)

55% coverage (after deductible)

80% coverage (after deductible)

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

80% cov (after deductible)

60% coverage (ded applies)

$600 per day 1st 5 days

70% coverage

$600 per day per admit ($3000 max)

$300 or $600 copay (1st 5 days)

$600 per day per admit ($3000 max)

$250 per day 1st 5 days

60% coverage (ded applies)

$150 copay

70% coverage (ded applies)

$500 per admission

$100 or $250 copay (1st 5 days)

70% coverage

80% coverage (ded applies)

90% coverage

Outpatient Psych

100% coverage (after deductible)

$65 copayment first 3 visits then deductible applies

100% coverage (after ded)

80% coverage (ded applies)

$50 copayment

$55 copayment

$50 copayment

$55 copayment

$50 copayment

80% coverage (ded applies)

$50 copayment

$65 copay 1st 3 visits then ded applies

$25 copayment

$30 copayment

$25 copayment

$15 copayment

$50 copayment

60% coverage (ded applies)

$15 copayment

$10 copayment

$15 copayment

$30 copayment

$50 copayment

$15 copayment

Rx Tier 1

100% coverage (after deductible)

$500 Rx ded then $18 ded per Rx

100% cov after ded (up to $250 per Rx)

$5 copay after ded

80% coverage to $250 max ben (ded applies)

$25 copayment

$20 copay

$17 copayment (after $300 Rxd ed)

$20 copay

$500 Rx ded then $17 ded per Rx

$5 copayment (ded applies)

$17 copayment (after $300 Rx ded)

$18 copay (ded applies)

$15 copayment

$5 copayment

$19 copayment

$19 copay after ded

$5 copayment

$15 copayment

$5 copayment

$15 copayment

$17 copay after ded

$5 copayment

Rx Tier 2

100% coverage (after deductible)

$500 Rx ded then $500 max ben per Rx

100% cov after ded (up to $250 per Rx)

$15 copayment (ded applies)

80% coverage to $250 max ben (ded applies)

$55 copayment

$75 copay (after $350 Rx ded)

$65 copayment (after $300 Rx ded)

$75 copay (after $350 Rx ded)

$65 copay (after $300 Rx ded)

$15 copayment (ded applies)

$65 copayment (after $300 Rx ded)

60% cov up to $500 per Rx after Rx ded

$50 copayment

$15 copayment

$65 copayment (ded applies)

$15 copayment

$40 copayment (ded applies)

$15 copayment

$40 copayment

$65 copay after ded

$15 copayment

Rx Tier 3

100% coverage (after deductible)

$500 Rx ded then $500 max ben per Rx

100% cov after ded (up to $250 per Rx)

$40 copayment (ded applies)

80% coverage to $250 max ben (ded applies)

$125 copayment

$75 copay (after $350 Rx ded)

$90 copayment (after $300 Rxded)

$75 copay (after $350 Rx ded)

$65 copay (after $300 Rx ded)

$40 copayment (ded applies)

$90 copayment (after $300 Rx ded)

60% cov up to $500 per Rx after Rx ded

$80 copayment

$75 copayment

$50 copayment

$80 copayment

$50 copayment

$25 copayment

60% cov up to $250 per Rx after ded

$85 copayment (ded applies)

$15 copayment

$70 copayment (ded applies)

$15 copayment

$25 copayment

$70 copayment

$90 copay after ded

$25 copayment

Rx Tier 4

100% coverage (after deductible)

$500 Rx ded then $500 max ben per Rx

100% cov after ded (up to $250 per Rx)

80% coverage (up to $500 per 30 day script after ded)

80% coverage to $250 max ben (ded applies)

50% cov up to $250 per Rx (after med ded)

80% cov $250 max ben (after $350 Rx ded)

80% coverage up to $250 per Rx (after $300 Rxded)

80% cov $250 max ben (after $350 Rx ded)

80% cov $250 max ben (after $300 Rx ded)

80% coverage (up to $500 per 30 day script after ded)

80% cov up to $250 per Rx (after $300 Rx ded)

60% coverage (up to $500 per 30 day script after Rx ded)

80% coverage up to $250 per Rx

80% cov after ded (up to $250 per Rx)

80% coverage to $250 max ben (ded waived)

80% cov after ded (up to $250 per Rx)

80% coverage to $250 max ben (ded waived)

90% coverage (up to $250 per Rx)

60% coverage (up to $250 per 30 day script after ded)

90% cov up to $250 per Rx

70% coverage (up to $250 per 30 day script after ded)

90% cov up to $250 per Rx

90% cov after ded (up to $250 per Rx)

70% cov ($250 max per 30 day script)

80% coverage (up to $250 per 30 day script after Rx ded)

90% coverage (up to $250 per 30 day script)

Links

Brochure Formulary Providers

Crystal

257.92 fam 832.05

273.66 fam 881.97

274.17 fam 869.6

280.97 fam 891.17

299.1 fam 962.67

314.63 fam 997.92

318.37 fam 1023.77

319.29 fam 1012.7

324 fam 1041.63

334.8 fam 1075.89

355.25 fam 1126.76

356.19 fam 1129.75

363.88 fam 1154.14

366.3 fam 1161.81

377.58 fam 1197.58

388.38 fam 1245.83

392.14 fam 1243.77

392.53 fam 1258.99

398.98 fam 1265.47

406.71 fam 1289.98

414.32 fam 1314.12

444.67 fam 1424.38

447.24 fam 1418.53

449.39 fam 1439.35

450.67 fam 1429.4

465.75 fam 1477.25

470.89 fam 1493.54

497.18 fam 1576.93

Jarron

289.18

306.82

307.4

315.02

335.35

352.76

356.95

357.98

363.26

375.37

398.3

399.36

407.98

410.69

423.33

435.44

439.66

440.1

447.33

455.99

464.53

498.56

501.44

503.86

505.28

522.2

527.95

557.43

Jason Poullard

234.95

249.28

249.75

255.94

272.46

286.6

290

290.84

295.13

304.97

323.6

324.46

331.47

333.67

343.94

353.78

357.21

357.56

363.44

370.48

377.41

405.06

407.4

409.36

410.52

424.26

428.94

452.89

Total

782.05 w deps 1356.18

829.76 w deps 1438.07

831.32 w deps 1426.75

851.93 w deps 1462.13

906.91 w deps 1570.48

953.99 w deps 1637.28

965.32 w deps 1670.72

968.11 w deps 1661.52

982.39 w deps 1700.02

1015.14 w deps 1756.23

1077.15 w deps 1848.66

1080.01 w deps 1853.57

1103.33 w deps 1893.59

1110.66 w deps 1906.17

1144.85 w deps 1964.85

1177.60 w deps 2035.05

1189.01 w deps 2040.64

1190.19 w deps 2056.65

1209.75 w deps 2076.24

1233.18 w deps 2116.45

1256.26 w deps 2156.06

1348.29 w deps 2328.00

1356.08 w deps 2327.37

1362.61 w deps 2352.57

1366.47 w deps 2345.20

1412.21 w deps 2423.71

1427.78 w deps 2450.43

1507.50 w deps 2587.25