Public Agencies
| |
Employee Only |
Employee and 1 Dependent |
Employee and 2 or more Dependents |
| Region 1 |
$799.00 |
$1,725.00 |
$2,219.00 |
| Region 2 |
$775.00 |
$1,550.00 |
$2,010.00 |
| Region 3 |
$775.00 |
$1,475.00 |
$1,894.00 |
| Out of State |
$899.00 |
$1,899.00 |
$2,223.00 |
| Supplemental Plan to Medicare |
$461.00 |
$919.00 |
$1,471.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee and 1 Dependent |
Employee and 2 or more Dependents |
| California |
$750.00 |
$1,499.00 |
$1,927.00 |
| Out of State |
$899.00 |
$1,899.00 |
$2,223.00 |
| Supplemental Plan to Medicare |
$461.00 |
$919.00 |
$1,471.00 |
Maximum Out-of-Pocket Expense is $2,000 per person / $4,000 per 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.
