| Zip: 92804 |
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|
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|
Apply
|
| Monthly Total |
1428.92 |
1483.78 |
1507.66 |
| Plan Name |
Bronze 60 HMO
|
Bronze 60 HMO
|
Bronze 7500 Trio HMO
|
| Deductible |
5800 ($11,600 per family)
|
5800 ($11,600 per family)
|
$7500 ($15,000 fam)
|
| Coinsurance |
60% coverage for most services
|
60% coverage for most services
|
50% coverage for most services
|
| Out of Pocket Max |
$9800 (19,600 family)
|
$9800 (19,600 family)
|
$9800 (19,600 family)
|
| Ambulance |
60% coverage (ded applies)
|
60% coverage (ded applies)
|
50% coverage (ded applies)
|
| Chiropractic |
Not covered
|
Not covered
|
Not covered
|
| Durable Medical Equipt |
60% coverage (ded applies)
|
60% coverage (ded applies)
|
50% coverage (ded applies)
|
| Emergency Room |
60% coverage (ded applies)
|
60% coverage (ded applies)
|
50% coverage (ded applies)
|
| Hospital Stay |
60% coverage (ded applies)
|
60% coverage (ded applies)
|
50% coverage (ded applies)
|
| Lab & X-ray |
$50 lab copay/60% x-ray after ded
|
$50 lab copay/60% x-ray after ded
|
$65 lab/$115 x-ray
|
| Office Visit |
$60 copayment
|
$60 copayment
|
$65 copayment
|
| Specialist |
$95 copay (ded applies)
|
$95 copay (ded applies)
|
$85 copayment
|
| Physical Therapy |
$60 copayment
|
$60 copayment
|
$65 copayment
|
| Outpatient Surgery |
60% coverage (ded applies)
|
60% coverage (ded applies)
|
50% coverage (ded applies)
|
| Psych (Inpatient) |
60% coverage after ded
|
60% coverage after ded
|
50% coverage (ded applies)
|
| Psych (Outpatient) |
$60 copayment
|
$60 copayment
|
$65 copayment
|
| Rx Tier 1 |
$20 copay
|
$20 copay
|
$25 copay
|
| Rx Tier 2 |
60% coverage up to $500 per Rx after $450 Rx ded
|
60% coverage up to $500 per Rx after $450 Rx ded
|
$115 copay after med ded
|
| Rx Tier 3 |
60% coverage up to $500 per Rx after $450 Rx ded
|
60% coverage up to $500 per Rx after $450 Rx ded
|
$160 copay after med ded
|
| Rx Tier 4 |
60% coverage up to $500 per Rx after $450 Rx ded
|
60% coverage up to $500 per Rx after $450 Rx ded
|
50% coverage up to $500 per Rx (after med ded)
|
| Links |
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
| Subscriber (55) |
746.25
|
774.90
|
787.37
|
| Spouse (53) |
682.67
|
708.88
|
720.28
|
| Annual Premium Tota |
$ 17,147 |
$ 17,805 |
$ 18,092 |
| Annual Max Exposure |
$ 26,947Family: $ 36,747 |
$ 27,605Family: $ 37,405 |
$ 27,892Family: $ 37,692 |