| Zip: 92804 |
Apply
|
Apply
|
Apply
|
| Monthly Total |
3840.62 |
3860.04 |
4241.38 |
| Plan Name |
Bronze 60 HDHP PPO
|
Bronze 60 PPO
|
Silver 2600 HDHP PPO
|
| Deductible |
$7200 ($14,400 per family)
|
5800 ($11,600 per family)
|
$2600 or 3400 ($5200 family)
|
| Coinsurance |
Not applicable
|
60% coverage for most services
|
65% coverage for most services
|
| Out of Pocket Max |
$7200 ($14,400 per family)
|
$9800 (19,600 family)
|
$7350 ($14,700 family)
|
| Ambulance |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Chiropractic |
Not covered
|
Not covered
|
65% coverage (ded applies)
|
| Durable Medical Equipt |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Emergency Room |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Hospital Stay |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Lab & X-ray |
100% coverage after deductible is met
|
$50 lab copay/60% x-ray after ded
|
65% coverage (ded applies)
|
| Office Visit |
100% coverage after deductible is met
|
$60 copayment
|
65% coverage (ded applies)
|
| Specialist |
100% coverage after deductible is met
|
$95 copay (ded applies)
|
65% coverage (ded applies)
|
| Physical Therapy |
100% coverage after deductible is met
|
$60 copayment
|
65% coverage (ded applies)
|
| Outpatient Surgery |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Psych (Inpatient) |
100% coverage after deductible is met
|
60% coverage after ded
|
65% coverage (ded applies)
|
| Psych (Outpatient) |
100% coverage after deductible is met
|
$60 copayment
|
65% coverage (ded applies)
|
| Rx Tier 1 |
100% coverage after deductible is met
|
$20 copay
|
65% cov to $250 per Rx (med ded applies)
|
| Rx Tier 2 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
65% cov to $250 per Rx (med ded applies)
|
| Rx Tier 3 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
65% cov to $250 per Rx (med ded applies)
|
| Rx Tier 4 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
65% cov to $250 per Rx (med ded applies)
|
| Links |
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
| Subscriber (55) |
1058.27
|
1063.62
|
1168.70
|
| Spouse (53) |
968.10
|
973.00
|
1069.12
|
| Child (22) |
474.56
|
476.96
|
524.08
|
| Child (20) |
460.32
|
462.65
|
508.36
|
| Child (19) |
446.56
|
448.82
|
493.16
|
| Child (18) |
433.27
|
435.46
|
478.49
|
| Child (17) |
0
|
0
|
0
|
| Annual Premium Tota |
$ 46,093 |
$ 46,326 |
$ 50,903 |
| Annual Max Exposure |
$ 53,293Family: $ 60,493 |
$ 56,126Family: $ 65,926 |
$ 58,253Family: $ 65,603 |