| Zip: 92804 |
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|
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|
Apply
|
| Monthly Total |
2134.14 |
2168.34 |
2352.36 |
| Plan Name |
Silver 70 HDHP HMO 3600/25% PCP
|
Bronze 60 HMO
|
Silver 70 HMO 2850/50 PCP
|
| Deductible |
$3600 ($7200 family)
|
5800 ($11,600 per family)
|
$2850 ($5700 family)
|
| Coinsurance |
75% coverage for most services
|
60% coverage for most services
|
Fixed copayments for most services
|
| Out of Pocket Max |
$7000 ($14,000 family)
|
$9800 (19,600 family)
|
$8900 (17,800 family)
|
| Ambulance |
75% coverage (ded applies)
|
60% coverage (ded applies)
|
$250 copayment after deductible
|
| Chiropractic |
Not covered
|
Not covered
|
Not covered
|
| Durable Medical Equipt |
75% coverage (ded applies)
|
60% coverage (ded applies)
|
65% coverage (ded waived)
|
| Emergency Room |
75% coverage (ded applies)
|
60% coverage (ded applies)
|
$350 copay (ded applies)
|
| Hospital Stay |
75% coverage (ded applies)
|
60% coverage (ded applies)
|
65% coverage (ded applies)
|
| Lab & X-ray |
75% coverage (ded applies)
|
$50 lab copay/60% x-ray after ded
|
Lab $30 after ded/x-ray $70 after ded
|
| Office Visit |
75% coverage (ded applies)
|
$60 copayment
|
$50 copayment
|
| Specialist |
75% coverage (ded applies)
|
$95 copay (ded applies)
|
$80 copayment
|
| Physical Therapy |
75% coverage (ded applies)
|
$60 copayment
|
$50 copayment
|
| Outpatient Surgery |
75% coverage (ded applies)
|
60% coverage (ded applies)
|
$400 copay
|
| Psych (Inpatient) |
75% coverage (ded applies)
|
60% coverage after ded
|
65% coverage (ded applies)
|
| Psych (Outpatient) |
75% coverage (ded applies)
|
$60 copayment
|
$50 copayment
|
| Rx Tier 1 |
75% cov to $250 per Rx (med ded applies)
|
$20 copay
|
$20 copayment
|
| Rx Tier 2 |
75% cov to $250 per Rx (med ded applies)
|
60% coverage up to $500 per Rx after $450 Rx ded
|
$75 copay (after $450 Rx ded)
|
| Rx Tier 3 |
75% cov to $250 per Rx (med ded applies)
|
60% coverage up to $500 per Rx after $450 Rx ded
|
$75 copay (after $450 Rx ded)
|
| Rx Tier 4 |
75% cov to $250 per Rx (med ded applies)
|
60% coverage up to $500 per Rx after $450 Rx ded
|
65% cov up to $250 per Rx (after $450 Rx ded)
|
| Links |
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
| Subscriber (55) |
762.68
|
774.90
|
840.67
|
| Spouse (53) |
697.70
|
708.88
|
769.04
|
| Child (22) |
342.01
|
347.49
|
376.98
|
| Child (20) |
331.75
|
337.07
|
365.67
|
| Annual Premium Tota |
$ 25,610 |
$ 26,020 |
$ 28,228 |
| Annual Max Exposure |
$ 32,610Family: $ 39,610 |
$ 35,820Family: $ 45,620 |
$ 37,128Family: $ 46,028 |