| Public Agencies | Region 1 Northern CA | Region 2 Central CA | Region 3 LA/ Riverside/ San Bernardino | Out of State | Supplemental Plan to Medicare |
|---|---|---|---|---|---|
| Employee Only | $ 799.00 | $ 749.00 | $ 725.00 | $ 899.00 | $ 513.00 |
| Employee and One Dependent | $1,725.00 | $1,499.00 | $1,450.00 | $1,850.00 | $1,022.00 |
| Employee and Two or more Dependents | $2,199.00 | $1,960.00 | $1,894.00 | $2,223.00 | $1,635.00 |
| State | California | Out of State | Supplemental Plan to Medicare |
|---|---|---|---|
| Employee Only | $ 750.00 | $ 899.00 | $ 513.00 |
| Employee and One Dependent | $1449.00 | $1850.00 | $1022.00 |
| Employee and Two or more Dependents | $1,927.00 | $2,223.00 | $1,635.00 |
Maximum Out-of-Pocket Expense $2,000 per person/ $4,000 for a family.
Prescription Drugs
| Retail | |
|---|---|
| Generic | $10.00 copay |
| Brand Formulary | $25.00 copay |
| Brand Non-Formulary | $45.00 copay |
| Mail Order | |
|---|---|
| Generic | $20.00 copay |
| Brand Formulary | $40.00 copay |
| Brand Non-Formulary | $75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.