Zip: 92804 Apply Apply Apply
Monthly Total 2404.34 2432.79 2504.36
Plan Name Silver 70 Trio HMO Off Ex Silver 70 HMO Off Exchange Silver 70 HMO Off Exchange
Deductible $5200 ($10,400 family) $5200 ($10,400 family) $5200 ($10,400 family)
Coinsurance 70% coverage for most services 70% coverage for most services 70% coverage for most services
Out of Pocket Max $9800 (19,600 family) $9800 (19,600 family) $9800 (19,600 family)
Ambulance $250 copayment $250 copayment $250 copayment
Chiropractic Not covered Not covered Not covered
Durable Medical Equipt 80% coverage 80% coverage 80% coverage
Emergency Room $400 copay $400 copay $400 copay
Hospital Stay 70% coverage (ded applies) 70% coverage (ded applies) 70% coverage (ded applies)
Lab & X-ray $50 lab/$95 x-ray $50 lab/$95 x-ray $50 lab/$95 x-ray
Office Visit $50 copayment $50 copayment $50 copayment
Specialist $90 copayment $90 copayment $90 copayment
Physical Therapy $50 copayment $50 copayment $50 copayment
Outpatient Surgery 70% coverage (ded waived) 70% coverage (ded waived) 70% coverage (ded waived)
Psych (Inpatient) 70% coverage 70% coverage 70% coverage
Psych (Outpatient) $50 copayment $50 copayment $50 copayment
Rx Tier 1 $19 copayment $19 copayment $19 copayment
Rx Tier 2 $60 copayment (after $50 Rx ded) $60 copayment (after $50 Rx ded) $60 copayment (after $50 Rx ded)
Rx Tier 3 $90 copayment (after $50 Rx ded) $90 copayment (after $50 Rx ded) $90 copayment (after $50 Rx ded)
Rx Tier 4 80% coverage up to $250 per Rx (after $50 Rx ded) 80% coverage up to $250 per Rx (after $50 Rx ded) 80% coverage up to $250 per Rx (after $50 Rx ded)
Links Brochure Providers Formulary Brochure Providers Formulary Brochure Providers Formulary
Subscriber (55) 859.24 869.41 894.99
Spouse (53) 786.03 795.33 818.73
Child (22) 385.31 389.87 401.34
Child (20) 373.75 378.17 389.30
Annual Premium Tota $ 28,852 $ 29,193 $ 30,052
Annual Max Exposure $ 38,652Family: $ 48,452 $ 38,993Family: $ 48,793 $ 39,852Family: $ 49,652
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