Prepared for Edy TransportZip code 90808Eff date 4/2021

Plan

CommunityCare Bronze 60 HMO 6300/65 + Child Dental

Silver Priority Select HMO 55/2250/45% 5SXC

CommunityCare HMO Silver $1750/$50

Salud HMO Silver $50

Silver Priority Select HMO 55 5STF

Silver Select HMO 55/2250/45% 5SX4

Silver Trio HMO 2350/65 OffEx

Trio Silver 70 HMO 2250/55 w Child Dental (shop)

Gold Priority Select HMO 35/1250/20% 5SSB

WholeCare HMO Silver $50

Gold Priority Select HMO 35/700/20% 5SS7

Full Network HMO Silver $50

Metal

Bronze

Silver

Silver

Silver

Silver

Silver

Silver

Silver

Gold

Silver

Gold

Silver

Network

CommunityCare HMO

Priority Select HMO

CommunityCare HMO

Salud HMO

Priority Select HMO

Select HMO

Trio ACO Network

Trio ACO Network

Priority Select HMO

WholeCare HMO

Priority Select HMO

Full Network HMO

Deductible

$6300/$12,600 family

$2250/$4500 family

$1750/$3500 family

None

None

$2250/$4500 family

$2350/$4700 family

$2250/$4500 family

$1250/$2500 family

None

$700/$2100 family

None

Coinsurance

Fixed copays for most services

55% coverage for most services

Fixed copays for most services

50% coverage for most services

Fixed copays for most services

55% coverage for most services

Fixed copays for most services

80% coverage for most services

80% coverage for most services

50% coverage for most services

80% coverage for most services

50% coverage for most services

Out of Pocket Mzx

$8200/$16,400 family

$8150/$16,300 family

$7800/$15,600 family

$7950/$15,900 family

$8400/$16,800 family

$8150/$16,300 family

$8150/$16,300 family

$8200/$16,400 family

$8400/$16,800 family

$7950/$15,900 family

$8400/$16,800 family

$7950/$15,900 family

Ambulance

60% coverage (ded applies)

55% coverage (ded applies)

60% coverage (ded applies)

50% coverage

$150 copaylment

55% coverage (ded applies)

$175 copayment (after ded)

70% coverage (after ded)

80% coverage (ded applies)

50% coverage

80% coverage (ded applies)

50% coverage

Chiropractor

Optional

20 visits max

Optional

Optional

20 visits max

20 visits max

$15 copayment (20 visits max)

Not covered

20 visits max

Optional

20 visits max

Optional

Durable Med Equip

60% coverage (ded applies)

50% coverage (ded applies)

60% coverage (ded applies)

50% coverage

$100 copayment

50% coverage (ded applies)

50% coverage (after deductible)

70% coverage (ded waived)

50% coverage (ded applies)

50% coverage

50% coverage (ded applies)

50% coverage

Emergency Room

60% coverage (ded applies)

$350 copay then 55% coverage after ded

60% coverage (ded applies)

50% coverage

$450 copayment

$350 copay then 55% coverage after ded

50% coverage (after deductible)

70% coverage (after ded)

$350 copay then 80% coverage after ded

50% coverage

$300 copay then 75% coverage

50% coverage

Hospital

60% coverage (ded applies)

55% coverage (ded applies)

60% coverage (ded applies)

50% coverage

$600 daily 1st 5 days

55% coverage (ded applies)

55% coverage (after deductible)

70% coverage (after ded)

80% coverage (ded applies)

50% coverage

80% coverage (ded applies)

50% coverage

Infertility

Optional

Optional

Optional

Optional

Optional

Optional

Optional

Not covered

Optional

Optional

Optional

Optional

Lab & X-Ray

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

$20 lab/$20 X-ray copayment

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

Lab: $40 copay/X-ray $50 copay

$20 lab/$20 X-ray copayment

$20 lab/$20 X-ray copayment

Lab: $55 copay/X-ray: $100

$55 lab/$90 X-ray

$15 lab/$15 X-ray copayment

Lab: $40 copay/X-ray $50 copay

$15 lab/$15 X-ray copayment

Lab: $40 copay/X-ray $50 copay

Office Visit

$65 copay 1st 3 visits then ded applies

$55 copayment

$50 copayment

$50 copayment

$55 copayment

$55 copayment

$65 copayment

$55 copayment

$35 copayment

$50 copayment

$35 copayment

$50 copayment

Specialist

$95 copay 1st 3 visits then ded applies

$110 copayment

$70 copayment

$70 copayment

$110 copayment

$110 copayment

$75 copayment

$90 copayment

$60 copayment

$70 copayment

$55 copayment

$70 copayment

Outpatient Surgery

60% coverage (ded applies)

$500 copayment

60% coverage (ded applies)

50% coverage

$600 copayment

$500 copayment

$250 or $1000 copay after ded

70% coverage (after ded)

$500 copayment

50% coverage

$500 copayment

50% coverage

Physical Therapy

$65 copayment

$55 copayment

$50 copayment

$50 copayment

$55 copayment

$55 copayment

$65 copayment

$55 copayment

$35 copayment

$50 copayment

$35 copayment

$50 copayment

Inpatient Psych

60% coverage (ded applies)

55% coverage (ded applies)

60% coverage (ded applies)

50% coverage

$600 daily 1st 5 days

55% coverage (ded applies)

55% coverage (after deductible)

70% coverage (after ded)

80% coverage (ded applies)

50% coverage

80% coverage (ded applies)

50% coverage

Outpatient Psych

$65 copay 1st 3 visits then ded applies

$55 copayment

$50 copayment

$50 copayment

$55 copayment

$55 copayment

$65 copayment

$55 copayment

$35 copayment

$50 copayment

$35 copayment

$50 copayment

Rx Tier 1

$18 copay (after $500 Rx ded)

$20 copayment

$15 copayment

$20 copayment

$20 copayment

$20 copayment

$20 copayment (after $350 Rx ded)

$17 copayment (after $300 Rxd ed)

$20 copayment

$20 copayment

$15 copay

$20 copayment

Rx Tier 2

60% cov (up to $500 after $500 Rx ded)

$85 copayment after $300 Rx ded

60% cov (up to $250 per 30 per Rx after Rx ded)

50% (up to $450 per 30 day script after Rx ded)

$50 copayment after $400 Rx ded

$85 copayment after $300 Rx ded

$85 copayment (after $350 Rx ded)

$80 copayment (after $300 Rx ded)

$50 copayment after $250 Rx ded

50% (up to $450 per 30 day script after Rx ded)

$45 copay ($100 Rx ded applies)

50% (up to $450 per 30 day script after Rx ded)

Rx Tier 3

60% cov (up to $500 after $500 Rx ded)

$115 copayment after $300 Rx ded

60% cov (up to $250 per 30 per Rx after Rx ded)

50% (up to $250 per 30 day script after Rx ded)

$115 copayment after $400 Rx ded

$115 copayment after $300 Rx ded

$115 copayment (after $350 Rx ded)

$110 copayment (after $300 Rxded)

$110 copayment after $250 Rx ded

50% (up to $250 per 30 day script after Rx ded)

$85 copay ($100 Rx ded applies)

50% (up to $250 per 30 day script after Rx ded)

Rx Tier 4

60% cov (up to $500 after $500 Rx ded)

70% coverage to $250 after $300 Rx ded

60% cov (up to $250 per 30 per Rx after Rx ded)

50% cov up to $250 per 30 day script after Rx deductible

70% coverage to $250 max after $400 Rx ded

70% coverage to $250 after $300 Rx ded

55% cov to $250 after $35 Rx ded

70% coverage up to $250 per Rx (after $300 Rxded)

70% coverage to $250 max

50% cov up to $250 per 30 day script after Rx deductible

70% coverage to $100 max

50% cov up to $250 per 30 day script after Rx deductible

Links

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Eduard

403.74 fam 1209.91

410.34 fam 1229.7

442.06 fam 1324.76

443.91 fam 1330.3

448.89 fam 1345.22

458.85 fam 1375.07

461.08 fam 1381.76

462.33 fam 1385.51

470.5 fam 1409.99

478.52 fam 1434.02

479.79 fam 1437.82

494.41 fam 1481.65

Eduardo

216.48

220.02

237.03

238.02

240.69

246.03

247.23

247.9

252.28

256.58

257.26

265.1

Total

620.22 w deps 1426.39

630.36 w deps 1449.72

679.09 w deps 1561.79

681.93 w deps 1568.32

689.58 w deps 1585.91

704.88 w deps 1621.10

708.31 w deps 1628.99

710.23 w deps 1633.41

722.78 w deps 1662.27

735.10 w deps 1690.60

737.05 w deps 1695.08

759.51 w deps 1746.75