| Zip: 92804 |
Apply
|
Apply
|
| Monthly Total |
2961.26 |
2976.23 |
| Plan Name |
Bronze 60 HDHP PPO
|
Bronze 60 PPO
|
| Deductible |
$7200 ($14,400 per family)
|
5800 ($11,600 per family)
|
| Coinsurance |
Not applicable
|
60% coverage for most services
|
| Out of Pocket Max |
$7200 ($14,400 per family)
|
$9800 (19,600 family)
|
| Ambulance |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
| Chiropractic |
Not covered
|
Not covered
|
| Durable Medical Equipt |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
| Emergency Room |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
| Hospital Stay |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
| Lab & X-ray |
100% coverage after deductible is met
|
$50 lab copay/60% x-ray after ded
|
| Office Visit |
100% coverage after deductible is met
|
$60 copayment
|
| Specialist |
100% coverage after deductible is met
|
$95 copay (ded applies)
|
| Physical Therapy |
100% coverage after deductible is met
|
$60 copayment
|
| Outpatient Surgery |
100% coverage after deductible is met
|
60% coverage (ded applies)
|
| Psych (Inpatient) |
100% coverage after deductible is met
|
60% coverage after ded
|
| Psych (Outpatient) |
100% coverage after deductible is met
|
$60 copayment
|
| Rx Tier 1 |
100% coverage after deductible is met
|
$20 copay
|
| Rx Tier 2 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
| Rx Tier 3 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
| Rx Tier 4 |
100% coverage after deductible is met
|
60% coverage up to $500 per Rx after $450 Rx ded
|
| Links |
Brochure
Providers
Formulary
|
Brochure
Providers
Formulary
|
| Subscriber (55) |
1058.27
|
1063.62
|
| Spouse (53) |
968.10
|
973.00
|
| Child (22) |
474.56
|
476.96
|
| Child (20) |
460.32
|
462.65
|
| Annual Premium Tota |
$ 35,535 |
$ 35,715 |
| Annual Max Exposure |
$ 42,735Family: $ 49,935 |
$ 45,515Family: $ 55,315 |