| Plan |
5168
|
5169
|
5760
|
| Primary Care Office Visit |
CYD |
CYD |
$20 |
| Specialist Care Office Visit |
CYD |
CYD |
$35 |
| Cal. Year Ded. (in/out of Network) |
$2500/$5000 |
$5000/$10000 |
$500/$1500 |
| Max Out of Pocket (in/out of Network) |
$2500/$5000 |
$5000/$20000 |
$2000/$4000 |
| Pharmacy Option (High) |
100% after CYD |
100% after CYD |
10/30/50 |
| ER Co-Pay |
CYD |
CYD |
$150 |
| Phyician Services at Hospital and ER |
CYD |
CYD |
$50 |
| Hosipital Co-Pay |
CYD |
CYD |
$600 (opt 1) |
| HRA Amount |
$1800 |
$3600 |
$0 |
| Employee's Cost for Individual Coverage |
$0 |
na |
$0 |
| City's Cost for Individual Coverage |
$535.70 |
na |
$596.19 |
| Employee's Cost for Spouse Coverage |
na |
$521.51 |
$727.36 |
| Employee's Cost for Child/Children Coverage |
na |
$331.01 |
$488.88 |
| Employee's Cost for Family Coverage |
na |
$926.29 |
$1234.13 |
| |
|
|
|