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
Silver HMO A
Silver PPO C
Gold PPO E
Plan Name
Network Name
Health Net WholeCare
Anthem Pru Buyer PPO
Anthem Pru Buyer PPO
Benefits
In-Network
Non-Network
In-Network
Non-Network
In-Network
Non-Network
Deductible Ind/Family
None
N/A
$1,700 / $3,400
$3,400 / $6,800
$500 / $1,500
$2,000 / $4,000
$15 or $20 / $70 or $80 / $110 or $120 / 30% or 40% up to $250 **
$10 or $20 / $50 or $60 / $90 or $100 / 30% or 40% up to $250 **
$20 / (Tier’s 2-4) 50% up to $250
RX Benefit
Not Covered
Not Covered
Not Covered
PCP Office Visits
50% after deductible 50% after deductible
$55 Copayment
Not Covered
$50 Copayment
$30 Copayment
50% after deductible
Specialty Office Visits
$90 Copayment
Not Covered
$95 Copayment
$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
50% after deductible
$0 Copayment
Not Covered
$0 Copayment
$0 Copayment
50% after deductible
50% after deductible
Urgent Care
$55 Copayment
$50 Copayment
$30 Copayment
50% after deductible
Emergency Room
$300 Copay and 40% after deductible (copay waived if admitted)
$250 Copay and 20% after deductible (copay waived if admitted)
50% coinsurance
50% after deductible – Max $650 / Day
Hospital Services
50% after deductible – Max $650 / Day
40% after deductible
20% after deductible
$900/day – Max 5 days
Out-of- Pocket Maximum Employee Monthly Premiums
$10,150 / $20,300
$18,200 / $36,400
N/A
$9,100 / $18,200
$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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