Public Agencies
| |
EmployeeOnly |
Employee+1 Dependent |
Employee2+ Dependents |
| Region 1 |
$825.00 |
$1,875.00 |
$2,300.00 |
| Region 2 |
$820.00 |
$1,650.00 |
$2,100.00 |
| Region 3 |
$820.00 |
$1,600.00 |
$2,100.00 |
| Out of State |
$935.00 |
$1,899.00 |
$2,250.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee+1 Dependent |
Employee2+ Dependents |
| California |
$775.00 |
$1,525.00 |
$2,000.00 |
| Out of State |
$935.00 |
$1,899.00 |
$2,250.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
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.
