Presented By: Miranda Cruz License# 0J22743
Medical Benefit Comparison
CaliforniaChoice
CaliforniaChoice
Medical
Gold PPO E Anthem Blue Cross - Prudent Buyer - Small Group
Silver PPO C Anthem Blue Cross - Prudent Buyer - Small Group
Effective Date: 1/1/2026
Effective Date: 1/1/2026
Tier 2 (Preferred Brand Formulary)
PPO: Level 1: $50; Level 2: $60 (up to 30 day supply; Select Rx) OON: Not Covered PPO: Level 1: $90; Level 2: $100 (up to 30 day supply; Select Rx) OON: Not Covered PPO: Level 1: 30%; Level 2: 40% (up to $250 per Rx; prior auth. required) OON: Not Covered
PPO: Level 1: $70; Level 2: $80 (up to 30 day supply; Select Rx) OON: Not Covered PPO: Level 1: $110; Level 2: $120 (upto 30 day supply; Select Rx) OON: Not Covered PPO: Level 1: 30%; Level 2: 40% (up to $250 per Rx; prior auth. required) OON: Not Covered
Tier 3 (Non-Preferred Brand Formulary)
Tier 4 (Specialty Drugs)
Mail Order
PPO: See Formulary Guide OON: Not Applicable
PPO: See Formulary Guide OON: Not Applicable
HOSPITAL FACILITY SERVICES
Inpatient Hospital Services
PPO: 20% after ded OON: 50% after ded ($650/day benefit limit) PPO: $250 + 20% after ded OON: 50% after ded ($380/admit benefit limit) PPO: $50 + 20% after ded OON: 50% after ded ($380/admit benefit limit)
PPO: 40% after ded OON: 50% after ded ($650/day benefit limit) PPO: $250 + 40% after ded OON: 50% after ded ($380/admit benefit limit) PPO: $50 + 40% after ded OON: 50% after ded ($380/admit benefit limit)
Outpatient Surgery in a Hospital Ambulatory Surgical Center
EMERGENCY SERVICES
Emergency Room
PPO: $250 + 20% after ded (copay waived if admitted) OON: $250 + 20% after ded (copay waived if admitted)
PPO: $300 + 40% after ded (copay waived if admitted) OON: $300 + 40% after ded (copay waived if admitted)
Emergency Transport/Ambulance
PPO: 20% after ded/trip OON: 20% after ded/trip PPO: $30 (ded waived) OON: 50% after ded
PPO: 40% after ded OON: 40% after ded PPO: $50 (ded waived) OON: 50% after ded
Urgent Care
MENTAL HEALTH/SUBSTANCE USE DISORDER PPO: $30 (ded waived) OON: 50% after ded Outpatient Services
PPO: $50 (ded waived) OON: 50% after ded
Inpatient Services
PPO: 20% after ded OON: 50% after ded ($650/day benefit limit)
PPO: 40% after ded OON: 50% after ded ($650/day benefit limit)
MATERNITY
Prenatal and Postnatal Care
PPO: Prenatal: 0% (ded waived); Postnatal: $30 (ded waived) OON: 50% after ded
PPO: Prenatal: 0% (ded waived); Postnatal: $50 (ded waived) OON: 50% after ded
Final rates are determined by the Carrier. This quote is not valid without the separate general disclaimer. # Dependent children 21-25 years old are rated as adults. Dependent children may become ineligible for coverage on their 26th birthday; effective date of change may vary by carrier.
Create Date: 10/31/2025
Presented By: Miranda Cruz License# 0J22743
Sorted By: Carrier,PlanType,Premium(Ascending)
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