ZapIndex

Prepared for Church of the Open DoorZip code 91740Eff date 4/2021

Plan

Silver Priority Select HMO 55/2250/45% 5SXC

Silver Priority Select HMO 55 5STF

Gold Priority Select HMO 35/1250/20% 5SSB

Gold Priority Select HMO 35/700/20% 5SS7

Gold Priority Select HMO 35 5SX0

Gold Priority Select HMO 30 5SVL

Silver HMO 55/2250/45% 5SX8

Bronze PPO 5600/45% w/HSA 5STX

Silver HMO 55 5ST7

Platinum Priority Select HMO 25 5STT

Bronze PPO 6950/0% w/HSA WH 5T05 w dental

Bronze PPO 5600/45% w/HSA WH 5T01 w dental

Silver PPO 2500/35% w/HSA PrevRx 5T0V Single

Platinum Priority Select HMO 20 5SUN

Gold HMO 35/1250/20% 5SSF

Silver PPO 2000/30% w/HSA � RxC 5SW5 Single

Gold HMO 35/700/20% 5SRZ

Silver PPO 55/2500/45% 5SR1

Silver PPO 55/1850/35% 2LHZ

Gold HMO 35 5SWW

Silver PPO 55/2500/45% WH 5SZX w dental

Gold HMO 30 5SVG

Silver PPO 45/1750/40% WH 5SZT w dental

Gold PPO 5/1500/30% 5SRR

Gold PPO 35/1000/20% 5SZ2

Gold PPO 35/500/25% 5SQT

Gold PPO 30/750/20% 5SYU

Gold PPO 20/30% 5SXU

Gold PPO 35/500/25% WH 5SZK (with dental)

Platinum PPO 5/250/15% 5SRH

Platinum PPO 20/10% 5SVU

Metal

Silver

Gold

Silver

Bronze

Silver

Platinum

Bronze

Silver

Platinum

Gold

Silver

Gold

Silver

Gold

Silver

Gold

Silver

Gold

Platinum

Network

Priority Select HMO

CaliforniaCare HMO

Prudent Buyer PPO

CaliforniaCare HMO

Priority Select HMO

Prudent Buyer PPO

Priority Select HMO

CaliforniaCare HMO

Prudent Buyer PPO

CaliforniaCare HMO

Prudent Buyer PPO

CaliforniaCare HMO

Prudent Buyer PPO

CaliforniaCare HMO

Prudent Buyer PPO

Deductible

$2250/$4500 family

None

$1250/$2500 family

$700/$2100 family

None

$2250/$4500 family

$5600/$11,200 family

None

$6950/$13,900 family

$5600/$11,200 family

$2000 or $2800 ($4000 family)

None

$1250/$2500 family

$2000 or $2800 ($4000 family)

$700/$2100 family

$2500/$5000 family

$1850/$3700 family

None

$2500/$5000 family

None

$1750/$3500 family

$1500/$3000 family

$1000/$3000 family

$500/$1500 family

$750/$2250 family

None

$500/$1500 family

$250/$750 family

Coinsurance

55% coverage for most services

Fixed copays for most services

80% coverage for most services

Fixed copays for most services

55% coverage for most services

Fixed copays for most services

100% coverage after ded

55% coverage for most services

70% coverage for most services

Fixed copays for most services

80% coverage for most services

70% coverage for most services

80% coverage for most services

55% coverage for most services

65% coverage for most services

Fixed copays for most services

55% coverage for most services

Fixed copays for most services

60% coverage for most services

70% coverage for most services

80% coverage for most services

75% coverage for most services

80% coverage for most services

70% coverage for most services

75% coverage for most services

85% coverage for most services

90% coverage for most services

Out of Pocket Mzx

$8150/$16,300 family

$8400/$16,800 family

$6500/$13,000 family

$6000/$12,000 family

$8150/$16,300 family

$7000/$14,000 family

$8400/$16,800 family

$2350/$4700 family

$6950/$13,900 family

$7000/$14,000 family

$6950/$13,900 family

$2200/$4400 family

$8400/$16,800 family

$6750/$13,500 family

$8400/$16,800 family

$8150/$16,300 family

$8500/$17,000 family

$6500/$13,000 family

$8150/$16,300 family

$6000/$12,000 family

$8100/$16,200 family

$7500/$15,000 family

$7800/$15,600 family

$7400/$14,800 family

$7800/$15,600 family

$4000/$8000 family

Ambulance

55% coverage (ded applies)

$150 copaylment

80% coverage (ded applies)

$150 copayment

55% coverage (ded applies)

$150 copaylment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$150 copaylment

80% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

55% coverage (ded applies)

65% coverage (ded applies)

$150 copayment

55% coverage (ded applies)

$150 copayment

60% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

75% coverage (ded applies)

80% coverage (ded applies)

70% coverage

75% coverage (ded applies)

85% coverage (ded applies)

90% coverage (ded applies)

Chiropractor

20 visits max

$25 copayment (20 visits max)

20 visits max

$20 copayment (20 visits max)

20 visits max

$20 copayment (20 visits max)

20 visits max

$25 copayment (20 visits max)

20 visits max

$25 copayment (20 visits max)

20 visits max

Durable Med Equip

50% coverage (ded applies)

$100 copayment

50% coverage (ded applies)

$100 copayment

50% coverage (ded applies)

$100 copayment

100% coverage after ded

50% coverage (ded applies)

$100 copayment

50% coverage (ded applies)

$100 copayment

50% coverage (ded applies)

$100 copayment

50% coverage (ded applies)

50% coverage

50% coverage (ded applies)

50% coverage

Emergency Room

$350 copay then 55% coverage after ded

$450 copayment

$350 copay then 80% coverage after ded

$300 copay then 75% coverage

$300 copayment

$350 copay then 55% coverage after ded

55% coverage (ded applies)

$450 copayment

$250 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$250 copayment

$350 copay then 80% coverage after ded

70% coverage (ded applies)

$300 copay then 75% coverage

$100 copay then 55% coverage (ded apples)

$300 copay then 65% coverage (ded apples)

$300 copayment

$100 copay then 55% coverage (ded apples)

$300 copayment

$300 copay then 60% coverage (ded apples)

$250 copay then 70% coverage (ded applies)

$250 copay then 80% coverage (ded applies)

$250 copay then 75% coverage

$250 copay then 80% coverage

$250 copay then 70% coverage

$250 copay then 75% coverage

$250 copay then 85% coverage

$200 copayment then 90% coverage

Hospital

55% coverage (ded applies)

$600 daily 1st 5 days

80% coverage (ded applies)

$750 daily 1st 4 days

$600 daily 1st 4 days

55% coverage (ded applies)

$600 daily 1st 5 days

$450 daily 1st 4 days

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$300 daily 1st 3 days

80% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

55% coverage (ded applies)

65% coverage (ded applies)

$750 daily 1st 4 days

55% coverage (ded applies)

$600 daily 1st 4 days

60% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

75% coverage (ded applies)

80% coverage (ded applies)

70% coverage (ded applies)

75% coverage (ded applies)

85% coverage (ded applies)

90% coverage

Infertility

Optional

Lab & X-Ray

$20 lab/$20 X-ray copayment

$15 lab/$15 X-ray copayment

$20 lab/$20 X-ray copayment

55% coverage (ded applies)

$20 lab/$20 X-ray copayment

$10 lab/$10 X-ray copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$10 lab/$10 X-ray copayment

$15 lab/$15 X-ray copayment

70% coverage (ded applies)

$15 lab/$15 X-ray copayment

$20 lab/$20 X-ray copayment

$15 lab/$15 X-ray copayment

$20 lab/$20 X-ray copayment

$15 lab/$15 X-ray copayment

$20 lab/$20 X-ray copayment

$15 lab/$15 X-ray copayment

$10 lab/$10 X-ray copayment

Office Visit

$55 copayment

$35 copayment

$30 copayment

$55 copayment

55% coverage (ded applies)

$55 copayment

$20 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$20 copayment

$35 copayment

70% coverage (ded applies)

$35 copayment

$55 copayment

$35 copayment

$55 copayment

$30 copayment

$45 copayment

$5 copayment

$35 copayment

$30 copayment

$20 copayment

$35 copayment

$5 copayment

$15 copayment

Specialist

$110 copayment

$60 copayment

$55 copayment

$70 copayment

$55 copayment

$110 copayment

55% coverage (ded applies)

$110 copayment

$50 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$40 copayment

$60 copayment

70% coverage (ded applies)

$55 copayment

$85 copayment

$70 copayment

$85 copayment

$55 copayment

$95 copayment

$65 copayment

$60 copayment

$65 copayment

$55 copayment

$50 copayment

$65 copayment

$45 copayment

$30 copayment

Outpatient Surgery

$500 copayment

$600 copayment

$500 copayment

$450 copayment

$300 copayment

$500 copayment

55% coverage (ded applies)

$600 copayment

$250 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$150 copayment

$500 copayment

70% coverage (ded applies)

$500 copayment

55% coverage (ded applies)

65% coverage (ded applies)

$450 copayment

55% coverage (ded applies)

$300 copayment

60% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

75% coverage (ded applies)

80% coverage (ded applies)

70% coverage (ded applies)

75% coverage (ded applies)

85% coverage (ded applies)

90% coverage (ded applies)

Physical Therapy

$55 copayment

$35 copayment

$30 copayment

$55 copayment

55% coverage (ded applies)

$55 copayment

$25 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$20 copayment

$35 copayment

70% coverage (ded applies)

$35 copayment

$55 copayment

$35 copayment

$55 copayment

$30 copayment

$45 copayment

$5 copayment

$35 copayment

$15 lab/$15 X-ray copayment

$30 copayment

$20 copayment

$15 lab/$15 X-ray copayment

$5 copayment

$15 copayment

Inpatient Psych

55% coverage (ded applies)

$600 daily 1st 5 days

80% coverage (ded applies)

$750 daily 1st 4 days

$600 daily 1st 4 days

55% coverage (ded applies)

$600 daily 1st 5 days

$400 daily 1st 4 days

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$300 daily 1st 3 days

80% coverage (ded applies)

70% coverage (ded applies)

80% coverage (ded applies)

55% coverage (ded applies)

65% coverage (ded applies)

$750 daily 1st 4 days

55% coverage (ded applies)

$600 daily 1st 4 days

60% coverage (ded applies)

80% coverage (ded applies)

75% coverage (ded applies)

80% coverage (ded applies)

70% coverage

75% coverage (ded applies)

85% coverage (ded applies)

90% coverage

Outpatient Psych

$55 copayment

$35 copayment

$30 copayment

$55 copayment

55% coverage (ded applies)

$55 copayment

$20 copayment

100% coverage after ded

55% coverage (ded applies)

65% coverage (ded applies)

$20 copayment

$35 copayment

70% coverage (ded applies)

$35 copayment

$55 copayment

$35 copayment

$55 copayment

$30 copayment

$45 copayment

$5 copayment

$35 copayment

$30 copayment

$20 copayment

$35 copayment

$5 copayment

$15 copayment

Rx Tier 1

$20 copayment

$15 copay

$15 coayment

$20 copayment

65% coverage to $500 per Rx (ded applies)

$20 copayment

$10 coayment

100% coverage after ded

65% coverage to $500 per Rx (ded applies)

$20 copayment (after ded)

$10 coayment

$20 copayment

$20 copayment (after ded)

$15 copay

$20 copayment

$15 coayment

$20 copayment

$15 coayment

$20 copayment

$15 copayment

$5 copayment

$10 copayment

Rx Tier 2

$85 copayment after $300 Rx ded

$50 copayment after $400 Rx ded

$50 copayment after $250 Rx ded

$45 copay ($100 Rx ded applies)

$40 copayment

$85 copayment after $300 Rx ded

65% coverage to $500 per Rx (ded applies)

$50 copayment after $400 Rx ded

$35 copayment

100% coverage after ded

65% coverage to $500 per Rx (ded applies)

$65 copayment (after ded)

$35 copayment

$50 copayment after $250 Rx ded

$60 copayment (after ded)

$45 copay ($100 Rx ded applies)

$65 copayment

$60 copayment after $300 Rx ded

$40 copayment

$65 copayment

$40 copayment

$60 copayment after $300 Rx ded

$50 copay after $250 Rx ded

$45 copay after $250 Rx ded

$45 copay after $150 Rx ded

$45 copay after $250 Rx ded

$35 copayment

Rx Tier 3

$115 copayment after $300 Rx ded

$115 copayment after $400 Rx ded

$110 copayment after $250 Rx ded

$85 copay ($100 Rx ded applies)

$80 copayment

$115 copayment after $300 Rx ded

65% coverage to $500 per Rx (ded applies)

$115 copayment after $400 Rx ded

$70 copayment

100% coverage after ded

65% coverage to $500 per Rx (ded applies)

$100 copayment (after ded)

$70 copayment

$110 copayment after $250 Rx ded

$85 copayment (after ded)

$85 copay ($100 Rx ded applies)

$110 copayment

$100 copayment after $300 Rx ded

$80 copayment

$110 copayment

$80 copayment

$100 copayment after $300 Rx ded

$100 copay after $250 Rx ded

$85 copay after $250 Rx ded

$85 copay ($250 Rx ded applies)

$150 copay after $150 Rx ded

$85 copay ($250 Rx ded applies)

$70 copayment

Rx Tier 4

70% coverage to $250 after $300 Rx ded

70% coverage to $250 max after $400 Rx ded

70% coverage to $250 max

70% coverage to $100 max

70% coverage to $250 max

70% coverage to $250 after $300 Rx ded

65% coverage to $500 per Rx (ded applies)

70% coverage to $250 max after $400 Rx ded

70% coverage to $250 max

100% coverage after ded

65% coverage to $500 per Rx (ded applies)

70% coverage to $250 max (ded applies)

70% coverage to $250 max

70% coverage to $250 max (ded applies)

70% coverage to $100 max

70% coverage to $250 max

70% coverage to $250 max ($300 Rx ded applies)

70% coverage to $250 max

70% coverage to $250 max ($300 Rx ded applies)

70% coverage to $250 max after $150 Rx ded

70% coverage to $250 max after $250 Rx ded

70% coverage to $250 max

70% coverage to $250 max after $150 Rx ded

70% coverage to $250 max after $250 Rx ded

70% coverage to $250 max

Links

Brochure Formulary Providers

Annette Greek

513.31 fam 1003.95

561.53 fam 1098.27

588.57 fam 1151.15

600.19 fam 1173.88

625.87 fam 1224.11

638.94 fam 1249.67

641.51 fam 1254.69

675.03 fam 1320.26

701.74 fam 1372.5

709 fam 1386.7

712.68 fam 1393.9

715.67 fam 1399.74

718.91 fam 1406.08

722.58 fam 1413.26

735.64 fam 1438.8

745.37 fam 1457.83

750.15 fam 1467.18

750.67 fam 1468.19

761.93 fam 1490.23

782.16 fam 1529.79

791.19 fam 1547.45

798.63 fam 1562

805.54 fam 1575.51

858.45 fam 1679

875.36 fam 1712.08

886.12 fam 1733.12

891.32 fam 1743.29

918.88 fam 1797.19

926.64 fam 1812.37

1058.34 fam 2069.96

1098.63 fam 2148.76

David Anderson

330.03 fam 1206.37

361.04 fam 1319.71

378.42 fam 1383.25

385.89 fam 1410.56

402.41 fam 1470.93

410.81 fam 1501.64

412.46 fam 1507.67

434.01 fam 1586.45

451.19 fam 1649.24

455.85 fam 1666.28

458.22 fam 1674.95

460.14 fam 1681.97

462.23 fam 1689.6

464.58 fam 1698.19

472.98 fam 1728.9

479.24 fam 1751.77

482.31 fam 1763

482.64 fam 1764.21

489.89 fam 1790.7

502.89 fam 1838.23

508.7 fam 1859.46

513.48 fam 1876.94

517.92 fam 1893.17

551.94 fam 2017.52

562.82 fam 2057.29

569.73 fam 2082.55

573.08 fam 2094.79

590.79 fam 2159.53

595.79 fam 2177.8

680.46 fam 2487.31

706.37 fam 2582.01

David Newkirk

274.14 fam 1049.71

299.9 fam 1148.33

314.34 fam 1203.62

320.55 fam 1227.39

334.26 fam 1279.91

341.24 fam 1306.63

342.61 fam 1311.88

360.52 fam 1380.45

374.78 fam 1435.06

378.66 fam 1449.91

380.63 fam 1457.45

382.22 fam 1463.54

383.95 fam 1470.17

385.91 fam 1477.68

392.89 fam 1504.39

398.08 fam 1524.28

400.64 fam 1534.06

400.91 fam 1535.11

406.93 fam 1558.16

417.73 fam 1599.52

422.56 fam 1617.99

426.53 fam 1633.2

430.22 fam 1647.33

458.48 fam 1755.54

467.51 fam 1790.13

473.26 fam 1812.13

476.03 fam 1822.75

490.75 fam 1879.11

494.9 fam 1894.99

565.24 fam 2164.32

586.75 fam 2246.71

David Schaller

513.31 fam 1630.13

561.53 fam 1783.27

588.57 fam 1869.15

600.19 fam 1906.04

625.87 fam 1987.61

638.94 fam 2029.1

641.51 fam 2037.26

675.03 fam 2143.72

701.74 fam 2228.55

709 fam 2251.6

712.68 fam 2263.3

715.67 fam 2272.78

718.91 fam 2283.08

722.58 fam 2294.72

735.64 fam 2336.21

745.37 fam 2367.1

750.15 fam 2382.29

750.67 fam 2383.93

761.93 fam 2419.7

782.16 fam 2483.94

791.19 fam 2512.61

798.63 fam 2536.24

805.54 fam 2558.18

858.45 fam 2726.21

875.36 fam 2779.92

886.12 fam 2814.09

891.32 fam 2830.61

918.88 fam 2918.11

926.64 fam 2942.78

1058.34 fam 3361.02

1098.63 fam 3488.97

John Smith

268.86 fam 865.77

294.12 fam 947.12

308.29 fam 992.73

314.37 fam 1012.32

327.83 fam 1055.64

334.67 fam 1077.68

336.01 fam 1082

353.57 fam 1138.55

367.57 fam 1183.61

371.37 fam 1195.85

373.3 fam 1202.06

374.86 fam 1207.1

376.56 fam 1212.57

378.48 fam 1218.75

385.32 fam 1240.78

390.42 fam 1257.2

392.92 fam 1265.26

393.19 fam 1266.12

399.09 fam 1285.13

409.69 fam 1319.25

414.42 fam 1334.48

418.32 fam 1347.03

421.93 fam 1358.68

449.65 fam 1447.93

458.51 fam 1476.45

464.14 fam 1494.59

466.87 fam 1503.38

481.3 fam 1549.85

485.37 fam 1562.95

554.35 fam 1785.08

575.45 fam 1853.03

Ryan Berkman

220.9 fam 609.24

241.65 fam 666.47

253.29 fam 698.56

258.29 fam 712.35

269.34 fam 742.84

274.97 fam 758.35

276.07 fam 761.39

290.5 fam 801.19

301.99 fam 832.88

305.12 fam 841.5

306.7 fam 845.87

307.99 fam 849.42

309.38 fam 853.26

310.96 fam 857.62

316.58 fam 873.12

320.77 fam 884.67

322.83 fam 890.35

323.05 fam 890.96

327.9 fam 904.33

336.6 fam 928.33

340.49 fam 939.05

343.69 fam 947.88

346.66 fam 956.08

369.43 fam 1018.88

376.71 fam 1038.96

381.34 fam 1051.72

383.58 fam 1057.9

395.44 fam 1090.6

398.78 fam 1099.82

455.45 fam 1256.12

472.79 fam 1303.95

Total

2120.55 w deps 6365.17

2319.77 w deps 6963.17

2431.48 w deps 7298.46

2479.48 w deps 7442.54

2585.58 w deps 7761.04

2639.57 w deps 7923.07

2650.17 w deps 7954.89

2788.66 w deps 8370.62

2899.01 w deps 8701.84

2929.00 w deps 8791.84

2944.21 w deps 8837.53

2956.55 w deps 8874.55

2969.94 w deps 8914.76

2985.09 w deps 8960.22

3039.05 w deps 9122.20

3079.25 w deps 9242.85

3099.00 w deps 9302.14

3101.13 w deps 9308.52

3147.67 w deps 9448.25

3231.23 w deps 9699.06

3268.55 w deps 9811.04

3299.28 w deps 9903.29

3327.81 w deps 9988.95

3546.40 w deps 10645.08

3616.27 w deps 10854.83

3660.71 w deps 10988.20

3682.20 w deps 11052.72

3796.04 w deps 11394.39

3828.12 w deps 11490.71

4372.18 w deps 13123.81

4538.62 w deps 13623.43