| Zip: 92804 |
Apply
|
| Monthly Total |
1507.66 |
| Plan Name |
Bronze 7500 Trio HMO
|
| Deductible |
$7500 ($15,000 fam)
|
| Coinsurance |
50% coverage for most services
|
| Out of Pocket Max |
$9800 (19,600 family)
|
| Ambulance |
50% coverage (ded applies)
|
| Chiropractic |
Not covered
|
| Durable Medical Equipt |
50% coverage (ded applies)
|
| Emergency Room |
50% coverage (ded applies)
|
| Hospital Stay |
50% coverage (ded applies)
|
| Lab & X-ray |
$65 lab/$115 x-ray
|
| Office Visit |
$65 copayment
|
| Specialist |
$85 copayment
|
| Physical Therapy |
$65 copayment
|
| Outpatient Surgery |
50% coverage (ded applies)
|
| Psych (Inpatient) |
50% coverage (ded applies)
|
| Psych (Outpatient) |
$65 copayment
|
| Rx Tier 1 |
$25 copay
|
| Rx Tier 2 |
$115 copay after med ded
|
| Rx Tier 3 |
$160 copay after med ded
|
| Rx Tier 4 |
50% coverage up to $500 per Rx (after med ded)
|
| Links |
Brochure
Providers
Formulary
|
| Subscriber (55) |
787.37
|
| Spouse (53) |
720.28
|
| Annual Premium Tota |
$ 18,092 |
| Annual Max Exposure |
$ 27,892Family: $ 37,692 |