|
|
|
|
NHP
Choice Saver Plus $2,400 Ded (HSA) |
NHP
Choice Saver Plus $2,400 Ded (HSA) |
Shield
Spectrum PPO Savings $2,400 Ded (HSA) |
Shield
Spectrum PPO Savings $2,400 Ded (HSA) |
Health
Net SmartChoice HSA $2,500 Ded (HSA) |
Health
Net SmartChoice HSA $2,500 Ded (HSA) |
Blue
Cross Individual PPO $3,500 Ded (HSA) |
Blue
Cross Individual PPO $3,500 Ded (HSA) |
|
BENEFITS |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
|
Lifetime
Maximum |
$5,000,000 |
$6,000,000 |
$6,000,000 |
$5,000,000 |
Maximum
Annual Out-of Pocket (Deductible
not Included) |
Not
Applicable |
$5,200
Individual/$10,400 Family |
$800
Individual/$1,000 Family |
$1,500
Individual/$5,000 Family Combined In and
Out of Network |
$5,000
Individual/$10,000 Family Combined In
and Out-of-Network |
|
Calendar
Year Deductible |
$2,400
Individual/$4,800 Family |
$2,400
Individual/$4,800 Family |
$2,500
Individual/$5,000 Family |
$3,500
Individual/ $7,000 Family |
|
Ambulance
Transportation |
0% |
0% |
30% |
30% |
30% |
50% |
0% |
50%,
plus 100% of excess charges |
|
Emergency
Hospital |
0% |
0% |
30% |
30% |
30% |
30% |
$100 copay, then 0% (Waived
if admitted) |
All
charges in excess of 100% of C & R
for the first 48 hrs. After 48 hrs., all
charges except $650 per day |
|
Emergency
Room Use |
0% |
50% |
$75 copay then 30% (copay
waived if admitted) |
$75 copay then 30% (copay
waived if admitted) |
$70 copay then 30% (Copay
waived if admitted) |
$70 copay then 30% (Copay
waived if admitted) |
$100 copay, then 0% (Waived
if admitted) |
All
charges in excess of 100% of C & R
for the first 48 hrs. After 48 hrs., all
charges except $650 per day |
|
|
|
|
|
50% |
|
|
|
|
|
Maternity |
No
Benefit |
No
Benefit |
30% |
($300
max per day for delivery and all |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
|
|
|
|
|
inpatient
hospital services) |
|
|
|
|
|
Durable
Medical Equipment |
0% ($5,000
maximum per calendar year) |
50% ($5,000
maximum per calendar year) |
30% ($2,000
maximum per member per year) |
50% ($2,000
maximum per member per year) |
50% ($2,000
annual maximum) |
No
Benefit |
0% |
50%,plus
100% of excess charges |
|
Doctor
Visits |
0% |
All
Charges Over $25 per Visit |
30% |
50% |
30% |
50% |
0% |
50%, plus 100% of excess
charges |
Adult
Preventive Care * Annual
Office Visits |
0% Deductible
Waived ($200 max payable annual benefit
combined for all |
No
Benefit |
$35 copay, then 0% Deductible
Waived |
No
Benefit |
$70 copay then 0% Deductible
Waived |
No
Benefit |
Healthy Check Center co-pay: $25
or $75 (Deductible Waived) Non-healthy
check center: 0%
after |
50%,
plus 100% of excess charges |
|
|
Adult
Preventive Care Services) |
|
|
|
|
|
deductible |
|
|
*
Annual Physical Lab & Diagnostics |
0% Deductible
Waived ($200 max payable annual benefit
combined for all Adult Preventive Care
Services) |
No
Benefit |
0% (if
all preventative services in one visit)
30% (if
annual physical in separate visit) Deductible
Waived |
No
Benefit |
$35 copay then 0% Deductible
Waived |
No
Benefit |
0% |
50%,
plus 100% of excess charges |
|
*
Routine Mammography & Pap Test |
0% Deductible
Waived ($200 max payable annual benefit
combined for all Adult Preventive Care
Services) |
No
Benefit |
0% (if
all preventative services in one visit)
30% (if
annual physical in separate visit) Deductible
Waived |
No
Benefit |
$35 copay then 0% Deductible
Waived |
No
Benefit |
0% |
50%,
plus 100% of excess charges |
|
Child
Preventive Care |
0% Deductible
Waived |
No
Benefit |
No
Benefit |
No
Benefit |
$35 copay then 0% Deductible
Waived |
No
Benefit |
0% |
50%,
plus 100% of excess charges |
|
Physical
Therapy |
0% 12
visits per calendar year, combined with
Chiro Services ($500 max payable annual
benefit) |
50% 12
visits per calendar year, combined with
Chiro Services ($300 max payable annual
benefit) |
30% |
50% |
30% 20
visits per calendar year |
50% (members
responsible for all charges over $25 per
visit) 20 visits per calendar year |
0% 12
visits per calendar year combined with
chiropractic |
All
charges except $25 per visit 12 visits
per calendar year combined with chiropractic |
|
Chiropractic
Services |
0% 12
visits per calendar year, combined with
Chiro Services ($500 max payable annual
benefit) |
50% 12
visits per calendar year, combined with
Chiro Services($300 max payable annual
benefit) |
50% (member
responsible for all charges over $25 per
visit) 12 visits per calendar year |
No
Benefit |
50% (members
responsible for all charges over $20 per
visit) 12 visits per calendar year |
No
Benefit |
0% 12
visits per calendar year combined with
physical therapy |
All
charges except $25 per visit 12 visits
per calendar year combined with physical
therapy |
|
Optional
3-Tier Copay Program |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
No
Benefit |
|
|
0% |
|
|
|
|
|
Blue
Cross Formulary Drugs: $10 copay |
|
|
Prescription
Drugs |
at
a participating Pharmacy Using Your Medco
Rx Card |
No
Benefit |
30% (Oral
Contraceptives Included) |
30% (Oral
Contraceptives Included) |
30% |
No
Benefit |
generic
copay; $30 copay brand-name copay after
annual deductible; 50% |
50% of
the Drug Limited Fee Schedule within CA |
|
|
(Oral
Contraceptives Included) |
|
|
|
|
|
coinsurance
for non-formulary drugs |
|
