Medical Cont.
For more information on the health insurance and to find in-network providers, visit https://www.calchoice.com/ then select “Provider Search”.
OPTION
HMO
HMO
PPO
Platinum HMO A
Silver HMO A
Gold PPO E
Plan Name
Network Name
Kaiser Permanente
Health Net WholeCare
Anthem Pru Buyer PPO
Benefits
In-Network
Non-Network
In-Network
Non-Network
In-Network
Non-Network
Deductible Ind/Family
$0 / $0
N/A
None
N/A
$500 / $1,500
$2,000 / $4,000
$10 or $20 / $50 or $60 / $90 or $100 / 30% or 40% up to $250 **
$5 / $15 / $15 / 10% up to $250
$20 / (Tier’s 2 -4) 50% up to $250
RX Benefit
Not Covered
Not Covered
Not Covered
PCP Office Visits
$10 Copayment
Not Covered
$55 Copayment
Not Covered
$30 Copayment
50% after deductible
Specialty Office Visits
$20 Copayment
Not Covered
$75 Copayment
Not Covered
$60 Copayment
50% after deductible
Chiropractic Services
$15 Copay – Max 20/yr
$15 Copay – Max 20/yr
Not Covered
Not Covered
Not Covered
Not Covered
Preventive Exams
$0 Copayment
Not Covered
$0 Copayment
Not Covered
$0 Copayment
50% after deductible
Urgent Care
$10 Copayment
Not Covered
$75 Copayment
$30 Copayment
50% after deductible
Emergency Room
$200 Copayment
50% coinsurance
$250 Copay and 20% after deductible
50% copay after deductible – Max $650 / Day
Hospital Services
20% coinsurance after deductible
$500 / Admit
Not Covered
$750/day – Max 5 days
Out-of- Pocket Maximum Employee Monthly Premiums
$3,000 / $6,000
N/A
$9,200 / $18,400
N/A
$7,700 / $15,400
$15,400 / $30,800
Age Based Plans
Rates will vary by participant age. Please contact Human Resources for more information.
Out-of-Pocket Maximum includes Deductible, Rx, Office, Urgent Care & Emergency Room Copays
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