| Zip: 92804 |
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|
Apply
|
Apply
|
| Monthly Total |
2237.82 |
2316.13 |
2416.78 |
| Plan Name |
Silver 2600 HDHP PPO
|
Silver 1750 PPO
|
Silver 70 PPO Off Exchange
|
| Deductible |
$2600 or 3400 ($5200 family)
|
$1750 ($3500 per family)
|
$5200 ($10,400 family)
|
| Coinsurance |
65% coverage for most services
|
65% coverage for most services
|
70% coverage for most services
|
| Out of Pocket Max |
$7350 ($14,700 family)
|
$9250 (18,500 family)
|
$9800 (19,600 family)
|
| Ambulance |
65% coverage (ded applies)
|
65% coverage (ded applies)
|
$250 copayment
|
| Chiropractic |
65% coverage (ded applies)
|
$15 copay (15 visits per year)
|
Not covered
|
| Durable Medical Equipt |
65% coverage (ded applies)
|
65% coverage
|
80% coverage
|
| Emergency Room |
65% coverage (ded applies)
|
65% coverage (ded applies)
|
$400 copay
|
| Hospital Stay |
65% coverage (ded applies)
|
65% coverage (ded applies)
|
70% coverage (ded applies)
|
| Lab & X-ray |
65% coverage (ded applies)
|
Lab $50 copay / X-Ray 65% cov after ded
|
$50 lab/$95 x-ray
|
| Office Visit |
65% coverage (ded applies)
|
$55 copayment
|
$50 copayment
|
| Specialist |
65% coverage (ded applies)
|
$85 copayment
|
$90 copayment
|
| Physical Therapy |
65% coverage (ded applies)
|
65% coverage (ded applies)
|
$50 copayment
|
| Outpatient Surgery |
65% coverage (ded applies)
|
65% or 75% coverage/after deductible
|
70% coverage (ded waived)
|
| Psych (Inpatient) |
65% coverage (ded applies)
|
65% coverage (ded applies)
|
70% coverage
|
| Psych (Outpatient) |
65% coverage (ded applies)
|
$55 copayment
|
$50 copayment
|
| Rx Tier 1 |
65% cov to $250 per Rx (med ded applies)
|
$20 copay after $300 Rx deductible
|
$19 copayment
|
| Rx Tier 2 |
65% cov to $250 per Rx (med ded applies)
|
$75 copayment (after $300 Rx ded)
|
$60 copayment (after $50 Rx ded)
|
| Rx Tier 3 |
65% cov to $250 per Rx (med ded applies)
|
$90 copayment (after $300 Rx ded)
|
$90 copayment (after $50 Rx ded)
|
| Rx Tier 4 |
65% cov to $250 per Rx (med ded applies)
|
65% coverage up to $250 per Rx (after $300 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) |
1168.70
|
1209.60
|
1262.16
|
| Spouse (53) |
1069.12
|
1106.54
|
1154.62
|
| Annual Premium Tota |
$ 26,854 |
$ 27,794 |
$ 29,001 |
| Annual Max Exposure |
$ 34,204Family: $ 41,554 |
$ 37,044Family: $ 46,294 |
$ 38,801Family: $ 48,601 |