Primary Care Office Visit
| CYD
| CYD
| $25
| CYD+Coins
| CYD+Coins
|
Specialist Care Office Visit
| CYD
| CYD
| $60
| CYD+Coins
| CYD+Coins
|
Cal. Year Ded. (in/out of Network)
| $2500/$5000
| $5000/$10000
| $500/$1500
| $2500/$5000
| $5000/$10000
|
Max Out of Pocket (in/out of Network)
| $2500/$10000
| $5000/$20000
| $3000/$6000
| $5000/$10000
| $6850 (Emb);
$10000/$20000
|
Coinsurance
| 100%/0%
| 100%/0%
| 80%/20%
| 90%/10%
| 90%/10%
|
Pharmacy Option (High)
| 100% after CYD
| 100% after CYD
| 10/30/50
| 10/30/50 after CYD
| 10/30/50 after CYD
|
ER Co-Pay
| CYD
| CYD
| $300
| CYD+Coins
| CYD+Coins
|
Physician Services at Hospital and ER
| CYD
| CYD
| $100
| CYD+Coins
| CYD+Coins
|
Hosipital Co-Pay
| CYD
| CYD
| CYD+Coins
| CYD+Coins
| CYD+Coins
|
Preventative Care
| $0
| $0
| $0
| $0
| $0
|
HRA Amount
| $1800
| $3600
| NA
| $1800
| $3600
|
Employee’s Cost for Individual Coverage
| $55.01
| NA
| NA
| NA
| NA
|
City’s Cost for Individual Coverage
| $590.90
| NA
| $738.51
| $570.88
| NA
|
Employee’s Cost for Spouse Coverage
| NA
| $946.37
| $1019.14
| NA
| $787.84
|
Employee’s Cost for Child/Children Coverage
| NA
| $649.25
| $679.43
| NA
| $525.23
|
Employee’s Cost for Family Coverage
| NA
| $1476.03
| $1624.72
| NA
| $1255.96
|