Plan Name SimpleValue 40 Generic Rx SimpleValue 40 Combo Rx SimpleValue 30 Generic Rx SimpleValue 30 Combo Rx RightPlan 40 - Generic Only Rx Active Start 35 RightPlan 40 - Comprehensive Rx Active Start 25
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Benefits: SimpleValue 40 Generic Rx SimpleValue 40 Combo Rx SimpleValue 30 Generic Rx SimpleValue 30 Combo Rx RightPlan 40 - Generic Only Rx Active Start 35 RightPlan 40 - Comprehensive Rx Active Start 25
Annual Deductible In None None None None No Deductible None No Deductible None
Out None None None None No Deductible None No Deductible None
Maximum Annual Copay In Individual: $7,500 Individual: $7,500 Individual: $7,500 Individual: $7,500 $7,500 per member Individual: $7,500 $7,500 per member Individual: $6,000
Out Individual: $10,000 Individual: $10,000 Individual: $10,000 Individual: $10,000 $7,500 per member Individual: $10,000 $7,500 per member Individual: $8,000
Lifetime Maximum In $6,000,000 $6,000,000 $6,000,000 $6,000,000 $5,000,000 $6,000,000 $5,000,000 $6,000,000
Out $6,000,000 $6,000,000 $6,000,000 $6,000,000 $5,000,000 $6,000,000 $5,000,000 $6,000,000
Outpatient Benefits: SimpleValue 40 Generic Rx SimpleValue 40 Combo Rx SimpleValue 30 Generic Rx SimpleValue 30 Combo Rx RightPlan 40 - Generic Only Rx Active Start 35 RightPlan 40 - Comprehensive Rx Active Start 25
Office Visits In $40 $40 $30 $30 $40 $35 $40 $25
Out 50% 50% 50% 50% 50% 50% 50% 50%
Prescription Drugs In $10 Generic $10 Generic $35 Brand $50 or 50% whichever is greater Non-Formulary ($750 Brand Deductible) $10 Generic $10 Generic $35 Brand $50 or 50% whichever is greater Non-Formulary ($750 Brand Deductible) $10 Generic (RightPlan Generic Rx Drug Formulary Only) $10 Generic $35 Brand Formulary $50 or 50% whichever is greater Brand Non-Formulary; $750 Brand Deductible $10 Generic $30 Brand 50% Non-Formulary $500 Annual Brand Deductible $10 Generic $35 Brand Formulary $50 or 50% whichever is greater Brand Non-Formulary; $500 Brand Deductible
Out Not Covered Not Covered Not Covered Not Covered 50% of the Drug Limited Fee Schedule (RightPlan Generic Rx Drug Formulary Only) $10 Generic $35 Brand Formulary $50 or 50% whichever is greater Brand Non-Formulary; $750 Brand Deductible 50% of the Drug Limited Fee Schedule with $500 Annual Brand Deductible $10 Generic $35 Brand Formulary $50 or 50% whichever is greater Brand Non-Formulary; $500 Brand Deductible
Laboratory and Radiology In 40% 40% 30% 30% 40% 40% 40% 40%
Out 50% 50% 50% 50% 50% 50% 50% 50%
Annual physical exam In 40% 40% 30% 30% $25 or $75 Co-Pay at HealthyCheck Centers for Basic Screening $35 $25 or $75 Co-Pay at HealthyCheck Centers for Basic Screening $25
Out Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Annual OB-GYN exam In $40 $40 $30 $30 $40 plus 40% $35 $40 plus 40% $25
Out Not Covered Not Covered Not Covered Not Covered 50% Not Covered 50% Not Covered
Well Baby Care In $40 $40 $30 $30 $40 plus 40% $35 $40 plus 40% $25
Out Not Covered Not Covered Not Covered Not Covered 50% Not Covered 50% Not Covered
Outpatient Surgery In $400 plus 40% $400 plus 40% $400 plus 30% $400 plus 30% $500 per admission plus 40% 40% plus $500 per admission $500 per admission plus 40% 40% plus $500 per admission
Out $400 plus 50% ($600 maximum per day) $400 plus 50% ($600 maximum per day) $400 plus 50% ($600 maximum per day) $400 plus 50% ($600 maximum per day) All Charges Except $380 per day 50% ($250 maximum benefit per day) All Charges Except $380 per day 50% ($250 maximum benefit per day)
Emergency Room In 40% plus $50 (waived if admitted) 40% plus $50 (waived if admitted) 30% plus $50 (waived if admitted) 30% plus $50 (waived if admitted) 40% plus $100 (waived if admitted) $35 (waived if admitted), then 40% 40% plus $100 (waived if admitted) $25 (waived if admitted), then 40%
Out 40% plus $50 (waived if admitted) 40% plus $50 (waived if admitted) 30% plus $50 (waived if admitted) 30% plus $50 (waived if admitted) 40% of customary and reasonable for the first 48 hours.After 48 hours:All charges except $650/day plus $100* $35 (waived if admitted), then 40% 40% of customary and reasonable for the first 48 hours.After 48 hours:All charges except $650/day plus $100* $25 (waived if admitted), then 40%
Ambulance In 40% 40% 30% 30% 40% 40% 40% 40%
Out 40% 40% 30% 30% 50% 40% 50% 40%
Home Health Care In See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract 40% (90 visits per year) See Benefit Contract 40% (90 visits per year)
Out See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract Not Covered See Benefit Contract Not Covered
Other Benefits: SimpleValue 40 Generic Rx SimpleValue 40 Combo Rx SimpleValue 30 Generic Rx SimpleValue 30 Combo Rx RightPlan 40 - Generic Only Rx Active Start 35 RightPlan 40 - Comprehensive Rx Active Start 25
Mental Health Services In 40% ($30 maximum payable per visit, 20 visits maximum per year) 40% ($30 maximum payable per visit, 20 visits maximum per year) 30% ($30 maximum payable per visit, 20 visits maximum per year) 30% ($30 maximum payable per visit, 20 visits maximum per year) All charges except $25 per visit (20 visits per year, 1 visit per day) 40% (20 visits per year) All charges except $25 per visit (20 visits per year, 1 visit per day) 40% (20 visits per year)
Out Not Covered Not Covered Not Covered Not Covered All charges except $25 per visit (20 visits per year, 1 visit per day) Not Covered All charges except $25 per visit (20 visits per year, 1 visit per day) Not Covered
Chiropractic Care In 40% (12-visit calendar year maximum/$20 maximum payable per visit) 40% (12-visit calendar year maximum/$20 maximum payable per visit) 30% (12-visit calendar year maximum/$20 maximum payable per visit) 30% (12-visit calendar year maximum/$20 maximum payable per visit) 40% (12 visits per year) 40% (12 visits per year) 40% (12 visits per year) 40% (12 visits per year)
Out Not Covered Not Covered Not Covered Not Covered All charges except $25 per visit (12 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year) All charges except $25 per visit (12 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year)
Acupuncture / Acupressure In See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract All charges except $25 per visit (24 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year) All charges except $25 per visit (24 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year)
Out See Benefit Contract See Benefit Contract See Benefit Contract See Benefit Contract All charges except $25 per visit (24 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year) All charges except $25 per visit (24 visits per year) 50% (maximum benefit $25 per visit, 12 visits per year)
Inpatient Hospital Benefits: SimpleValue 40 Generic Rx SimpleValue 40 Combo Rx SimpleValue 30 Generic Rx SimpleValue 30 Combo Rx RightPlan 40 - Generic Only Rx Active Start 35 RightPlan 40 - Comprehensive Rx Active Start 25
inpatient Co-payment In $400 per day copay plus 40% (4 days copay maximum) $400 per day copay plus 40% (4 days copay maximum) $400 per day copay plus 30% (4 days copay maximum) $400 per day copay plus 30% (4 days copay maximum) 40% plus $500 per day (4 day maximum copay per admission) 40% plus $500 per admission 40% plus $500 per day (4 day maximum copay per admission) 40% plus $500 per admission
Out $400 per day copay plus 50% (4 days copay maximum, $600 maximum per day) $400 per day copay plus 50% (4 days copay maximum, $600 maximum per day) $400 per day copay plus 50% (4 days copay maximum, $600 maximum per day) $400 per day copay plus 50% (4 days copay maximum, $600 maximum per day) All Charges Except $650 per day 50% ($250 maximum benefit per day) All Charges Except $650 per day 50% ($250 maximum benefit per day)
Maternity Care In Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Out Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Mental Health In 40% ($300 maximum payable per visit, 30 days) 40% ($300 maximum payable per visit, 30 days) 30% ($300 maximum payable per visit, 30 days) 30% ($300 maximum payable per visit, 30 days) All charges except $175 per day (30 days per year) 40% plus $500 per admission All charges except $175 per day (30 days per year) 40% plus $500 per admission
Out 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) All charges except $175 per day (30 days per year) 50% ($250 maximum benefit per day) All charges except $175 per day (30 days per year) 50% ($250 maximum benefit per day)
Chemical Dependency In 40% ($300 maximum payable per visit, 30 days) 40% ($300 maximum payable per visit, 30 days) 30% ($300 maximum payable per visit, 30 days) 30% ($300 maximum payable per visit, 30 days) All charges except $175 per day (30 days per year) 40% plus $500 per admission All charges except $175 per day (30 days per year) 40% plus $500 per admission
Out 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) 50% ($300 maximum payable per visit, 30 days) All charges except $175 per day (30 days per year) 50% ($250 maximum benefit per day) All charges except $175 per day (30 days per year) 50% ($250 maximum benefit per day)
Plan Benefit Details
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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389