Medical Plan Features
We have prepared a chart that provides a broad comparison of the medical plans: Summary of medical plan benefits.
Here is a summary of out-of-pocket expenses:
1. Co-pay amounts for office calls
| Preferred Provider Organization (PPO) | $15 |
| Health Maintenance Organizations (HMO) | $15 |
2. Preferred Provider Organization (PPO) deductibles and out-of-pocket maximums
| Deductibles | In network | Out of network |
| Salary range | Single/family | Single/family |
| Less than $25,000 | $150/300 | $300/600 |
| $25,000 to $39,999 | $200/400 | $425/850 |
| $40,000 to $54,999 | $300/600 | $600/1,200 |
| $55,000 to $69,999 | $400/800 | $775/1,550 |
| $70,000 to $84,999 | $475/950 | $950/1,900 |
| $85,000 and higher | $600/1,200 | $1,200/2,400 |
| Out-of-pocket maximums | In network | Out of network |
| Salary Range | Single/family | Single/family |
| Less than $25,000 | $600/900 | $1800/2,700 |
| $25,000 to $39,999 | $850/1,250 | $2,500/3,800 |
| $40,000 to $54,999 | $1,200/1,800 | $3,600/5,400 |
| $55,000 to $69,999 | $1,550/2,350 | $4,700/7,000 |
| $70,000 to $84,999 | $1,900/2,900 | $5,750/8,650 |
| $85,000 and higher | $2,400/3,600 | $7,200/10,800 |
3. Annual deductible and out-of-pocket maximums for comprehensive plan
| Salary range | Deductibles: Single/family |
Out-of-pocket maximums: Single/family |
| Less than $25,000 | $150/300 | $600/900 |
| $25,000 to $39,999 | $200/400 | $850/1,250 |
| $40,000 to $54,999 | $300/600 | $1,200/1,800 |
| $55,000 to $69,999 | $400/800 | $1,550/2,350 |
| $70,000 to $84,999 | $475/950 | $1,900/2,900 |
| $85,000 and higher | $600/1,200 | $2,400/3,600 |
4. Prescription drug co-pay amounts
For the comprehensive and PPO plans:
| Via retail, 30-day maximum supply | |
| Generic, 90% subject to minimums and maximums co-pay amounts as shown. | $10/$20 |
| Brand, 80% subject to minimums and maximums co-pay amounts as shown | $20/$50 |
For comprehensive and PPO plans:
| Via mail order, 90-day maximum supply | |
| Generic - 90% subject to minimums and maximums copay amounts as shown; | $25/$50 |
| Brand - 80% subject to minimums and maximums copay amounts as shown | $50/$100 |
For health maintenance organizations:
Applicable to Kaiser Permanente HMO:
| Via retail, 30-day maximum supply | ||
| Generic | $10 | |
| Brand | $20 | |
| Via mail order, 62-day maximum supply | ||
| Generic | $10 | |
| Brand | $20 | |
Applicable to SummaCare:
| Via retail, 30-day maximum supply | |
| Generic | $10 |
| Preferred Brand | $20 |
| Non-Preferred Brand | $40 |
| Via mail, 90-day maximum supply | |
| Generic | $20 |
| Preferred Brand | $40 |
| Non-Preferred Brand | $80 |
Applicable to The Health Plan:
| Via retail, 30-day maximum supply | |
| Generic | $10 |
| Preferred Brand | $20 |
| Non Preferred Brand | $50 |
| Via mail, 90-day maximum supply | |
| Generic | $20 |
| Preferred Brand | $40 |
| Non-Preferred Brand | $100 |
Other specific benefit plan features vary by individual HMO. Refer to our general summary of the HMO plans for complete details.