ZapIndex

Prepared for Beyond Balance 2020Zip code 94928Eff date 1/2019

Plan

Bronze 60 HMO 6300/65 (shop)

Trio Silver 70 HMO 2250/50 Plus Child Dental (shop)

Bronze 60 HDHP PPO 5600/20% + Child Dental Alt (shop)

Bronze 60 PPO 6300/65 + Child Dental (shop)

Trio Gold 80 HMO 250/25 w Child Dental (shop)

Silver 70 Value PPO 1700/50 + Child Dental Alt (shop)

Trio Platinum 90 HMO 0/15 w Child Dental (shop)

Silver 70 HDHP PPO 1400/40% + Child Dental Alt (shop)

Gold 80 Value PPO 750/15 + Child Dental Alt (shop)

Gold 80 PPO 0/30 + Child Dental Alt (shop)

Silver 70 PPO 2250/50 + Child Dental (shop)

Platinum 90 PPO 0/15 + Child Dental (shop)

Metal

Bronze

Silver

Bronze

Gold

Silver

Platinum

Silver

Gold

Silver

Platinum

Network

Kaiser Permanente

Trio ACO Network

Full PPO

Trio ACO Network

Full PPO

Trio ACO Network

Full PPO

Deductible

$6300/$12,600 family

$2250/$4500 family

$5600/$11,200 family

$6300/$12,600 family

$250/$500 family

$1700/$3400 family

None

$1400/$2800 family

$750/$1500 family

None

$2250/$4500 famly

None

Coinsurance

60% coverage for most services

80% coverage for most services

60% coverage for most services

Fixed copays for most services

60% coverage for most services

Fixed copays for most services

60% coverage for most services

70% coverage for most services

80% coverage for most services

90% coverage for most services

Out of Pocket Mzx

$7800/15,600 family

$7800/$15,600 family

$6850/$13,700 family

$7800/$15,600 family

$4500/9000 family

$6850/$13,700 family

$7600/$15,200 failily

$7400/$14,800 family

$7800/$15,600 family

$4500/$9000 family

Ambulance

60% coverage (after ded)

$250 copayment (after deductible)

80% coverage (ded applies)

60% coverage (ded applies)

$250 copayment

60% coverage (ded applies)

$150 copayment

60% coverage (ded applies)

$250 copayment (ded applies)

70% coverage

$250 copayment (ded applies)

$150 copaymet

Chiropractor

Not covered

Optional

Not covered

Optional

Not covered

Optional

Durable Med Equip

60% coverage (after ded)

80% coverage

80% coverage (ded applies)

60% coverage (ded applies)

80% coverage

60% coverage (ded applies)

90% coverage

60% coverage (ded applies)

70% coverage (ded applies)

70% coverage

80% coverage (ded waived)

90% coverage

Emergency Room

60% coverage (after ded)

$400 copay (after ded)

80% coverage (ded applies)

60% coverage (ded applies)

$250 copayment

60% coverage (ded applies)

$150 copayment

60% coverage (ded applies)

$250 copayment (ded applies)

70% coverage

$400 copayment (ded applies)

$150 copayment

Hospital

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

60% coverage (ded applies)

$600 per day 1st 5 days

60% coverage (ded applies)

$250 per day 1st 5 days

60% coverage (ded applies)

70% coverage (ded applies)

70% coverage

80% coverage (ded applies)

90% coverage

Infertility

Optional

Not covered

Optional

Not covered

Optional

Not covered

Optional

Lab & X-Ray

Lab $40/X-ray 60% coverage (after ded)

$40 lab/$85 X-ray

Lab: 80% coverage (ded applies)/X-ray 80% cov (ded applies)

Lab: $40 copay (ded waived)/X-ray 60% cov (ded applies)

$25 lab/$65 X-ray

Lab: $40 copay (ded applies)/X-ray $50 copay(ded applies)

Lab $15 copay / X-ray $30 copay

Lab: 60% coverage (ded applies)/X-ray 60% cov (ded applies)

Lab: $25 copay (ded applies)/X-ray $25 copay(ded applies)

Lab: $30 copay/X-ray $40 copay

Lab: $40 copay (ded waived)/X-ray $85 copay (ded waived)

Lab: $15 copay/X-ray $30 copay

Office Visit

$65 copayment first 3 visits then deductible applies

$50 copayment

80% coverage (ded applies)

$65 copay 1st 3 visits then ded applies

$25 copayment

$50 copayment

$15 copayment

60% coverage (ded applies)

$15 copayment

$30 copayment

$50 copayment

$15 copayment

Specialist

$95 copayment first 3 visits then deductible applies

$85 copayment

80% coverage (ded applies)

$95 copay 1st 3 visits then ded applies

$65 copayment

$75 copayment

$30 copayment

60% coverage (ded applies)

$30 copayment

$50 copayment

$85 copayment

$30 copayment

Outpatient Surgery

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

60% coverage (ded applies)

$300 copayment

60% coverage (ded applies)

$100 copayment

60% coverage (ded applies)

70% coverage (ded applies)

70% coverage

80% coverage (ded waived)

90% coverage

Physical Therapy

$65 copayment

$50 copayment (after deductible)

80% coverage

$65 copayment

$25 copayment

$50 copayment

$15 copayment

60% coverage

$50 copayment

$30 copayment

$50 copayment

$15 copayment

Inpatient Psych

60% coverage (after ded)

80% coverage (after deductible)

80% coverage (ded applies)

60% coverage (ded applies)

$600 per day 1st 5 days

60% coverage (ded applies)

$250 per day 1st 5 days

60% coverage (ded applies)

70% coverage (ded applies)

70% coverage

80% coverage (ded applies)

90% coverage

Outpatient Psych

$65 copayment first 3 visits then deductible applies

$50 copayment

80% coverage (ded applies)

$65 copay 1st 3 visits then ded applies

$25 copayment

$50 copayment

$15 copayment

60% coverage (ded applies)

$15 copayment

$30 copayment

$50 copayment

$15 copayment

Rx Tier 1

$500 Rx ded then $18 ded per Rx

$17 copayment (after $300 Rxd ed)

$5 copayment (ded applies)

$18 copay (ded applies)

$15 copayment

$19 copayment

$5 copayment

$19 copay after ded

$15 copayment

$17 copay after ded

$5 copayment

Rx Tier 2

$500 Rx ded then $500 max ben per Rx

$65 copayment (after $300 Rx ded)

$15 copayment (ded applies)

60% cov up to $500 per Rx after Rx ded

$50 copayment

$65 copayment (ded applies)

$15 copayment

$65 copayment (ded applies)

$40 copayment (ded applies)

$40 copayment

$65 copay after ded

$15 copayment

Rx Tier 3

$500 Rx ded then $500 max ben per Rx

$90 copayment (after $300 Rxded)

$40 copayment (ded applies)

60% cov up to $500 per Rx after Rx ded

$80 copayment

60% cov up to $250 per Rx after ded

$25 copayment

$85 copayment (ded applies)

$70 copayment (ded applies)

$70 copayment

$90 copay after ded

$25 copayment

Rx Tier 4

$500 Rx ded then $500 max ben per Rx

80% coverage up to $250 per Rx (after $300 Rxded)

80% coverage (up to $500 per 30 day script after ded)

60% coverage (up to $500 per 30 day script after Rx ded)

80% coverage up to $250 per Rx

60% coverage (up to $250 per 30 day script after ded)

90% coverage (up to $250 per Rx)

60% coverage (up to $250 per 30 day script after ded)

70% coverage (up to $250 per 30 day script after ded)

70% cov ($250 max per 30 day script)

80% coverage (up to $250 per 30 day script after Rx ded)

90% coverage (up to $250 per 30 day script)

Links

Brochure Formulary Providers

Gabriela

301.69

464.09

497.92

510.02

532.41

570.04

579.92

580.72

626.86

652.81

659.99

696.85

928.66

Jason

311.84

479.7

514.67

527.18

550.33

589.22

599.43

600.26

647.95

674.77

682.2

720.3

959.91

Joanna

316

486.11

521.55

534.22

557.68

597.09

607.44

608.27

656.6

683.79

691.31

729.92

972.73

Nina

780.9

1201.26

1288.83

1320.15

1378.11

1475.52

1501.08

1503.15

1622.58

1689.75

1708.35

1803.75

2403.78

Patricia

768.41

1182.04

1268.21

1299.03

1356.06

1451.91

1477.06

1479.1

1596.62

1662.71

1681.02

1774.89

2365.32

Susan

663.24 fam 923.54

1020.27 fam 1420.69

1094.65 fam 1524.26

1121.25 fam 1561.3

1170.47 fam 1629.84

1253.21 fam 1745.05

1274.92 fam 1775.28

1276.68 fam 1777.73

1378.11 fam 1918.97

1435.16 fam 1998.41

1450.96 fam 2020.41

1531.99 fam 2133.24

2041.61 fam 2842.87

Yessenia

363.64

559.39

600.17

614.75

641.74

687.1

699

699.97

755.58

786.86

795.52

839.95

1119.36

Total

3505.72 w deps 3766.02

5392.86 w deps 5793.28

5786.00 w deps 6215.61

5926.60 w deps 6366.65

6186.80 w deps 6646.17

6624.09 w deps 7115.93

6738.85 w deps 7239.21

6748.15 w deps 7249.20

7284.30 w deps 7825.16

7585.85 w deps 8149.10

7669.35 w deps 8238.80

8097.65 w deps 8698.90

10791.37 w deps 11592.63