Public Agencies
| |
EmployeeOnly |
Employee+1 Dependent |
Employee2+ Dependents |
| Region 1 |
$1,095.00 |
$2,395.00 |
$3,115.00 |
| Region 2 |
$1,020.00 |
$2,040.00 |
$2,650.00 |
| Region 3 |
$1,020.00 |
$2,040.00 |
$2,650.00 |
| Out of State |
$1,300.00 |
$2,600.00 |
$3,200.00 |
| Supplemental Plan to Medicare |
$640.00 |
$1,410.00 |
$1,925.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee+1 Dependent |
Employee2+ Dependents |
| California |
$980.00 |
$1,975.00 |
$2,570.00 |
| Out of State |
$1,300.00 |
$2,600.00 |
$3,200.00 |
| Supplemental Plan to Medicare |
$640.00 |
$1,410.00 |
$1,925.00 |
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 one scan every 36 months for the primary subscriber.
