Weekly Bi-Weekly Monthly
PPO $1,000 HSA $2,800 HSA $6,000 PPO $1,000 HSA $2,800 HSA $6,000 PPO $1,000 HSA $2,800 HSA $6,000
Employee $55.05 $29.49 $17.52 $110.09 $58.98 $35.03 $238.53 $127.78 $75.90
Employee + Spouse $143.97 $87.51 $57.51 $287.93 $175.02 $115.02 $623.85 $379.21 $249.20
Employee + Children $112.91 $66.34 $48.57 $225.83 $132.67 $97.13 $489.30 $287.46 $210.45
Family $228.65 $132.68 $87.45 $457.31 $265.35 $174.89 $990.83 $574.93 $378.94
PP0 $1,000 HSA $2,800 HSA $6,000
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $4,000 $2,800 $2,800 $6,000 $6,000
Family $3,000 $8,000 $5,600 $5,600 $12,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $3,000 $6,000 $7,050 $10,000 $7,050 $24,000
Family $6,000 $12,000 $14,100 $20,000 $14,100 $28,000
Physician Office Visits
Preventive Care Covered at 100% 40% coinsurance after deductible Covered at 100% 40% coinsurance after deductible Covered at 100% 40% coinsurance after deductible
Primary Care Visit $30 copay per visit 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Specialist Visit $50 copay per visit 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Telemedicine $50 copay per visit 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Urgent Care $100 copay per visit 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Hospital Services
Inpatient 20% coinsurance after deductible 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Outpatient 20% coinsurance after deductible 40% coinsurance after deductible 0% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Emergency Room $300 copay per visit $300 copay per visit 0% coinsurance after deductible 0% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
PP0 $1,000 HSA $2,800 HSA $6,000
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs (Essential Rx Formulary Listing)
Please note: for the HSA-qualified plans, all prescription drug expenses are subject to the medical deductible. Once you meet your deductible, copays or coinsurance will apply.
Generic $10 copay per prescription drug 50% coinsurance $10 copay 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Preferred Brand Formulary $35 copay per prescription drug 50% coinsurance $35 copay 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Non-Preferred Brand Formulary $70 copay per prescription drug 50% coinsurance $60 copay 40% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible
Mail Order
Generic $25 copay per prescription drug Not covered $25 copay Not covered 20% coinsurance after deductible Not covered
Preferred Brand Formulary $85 copay per prescription drug Not covered $85 copay Not covered 20% coinsurance after deductible Not covered
Non-Preferred Brand Formulary $175 copay per prescription drug Not covered $150 copay Not covered 20% coinsurance after deductible Not covered
Kaiser Permanente
Calendar Year Deductible
Individual $0
Family $0
Out-of-Pocket Maximum (includes deductible)
Individual $1,500
Family $3,000
Coinsurance 100%
Physician Office Visits
Preventive Care Covered at 100%
Primary Care Visit $35 copay per visit
Specialist Visit $35 copay per visit
Chiropractic Services (max 20 visits) $15 copay per visit
Hospital Services
Inpatient Hospitalization $500 copay per admit
Emergency Room $150 copay per visit
Urgent Care $35 copay per visit
Outpatient Services
X-Ray and Lab Tests $10 copay
Surgery $35 copay
Prescription Drugs
Generic $15 copay
Formulary/Brand $30 copay
Rates
LegalShield Only Monthly Rate
Monthly Rate $16.30
IDShield Only Monthly Rate
Employee $7.45
Family $14.05
IDShield & Legal Shield Monthly Rate
Employee $22.75
Family $28.35
Kaiser Permanente
Annual Deductible
Individual $0 (none)
Family $0 (none)
Out-of-Pocket Maximum (includes deductible)
Individual $2,500
Family $7,500
Coinsurance 20%
Physician Office Visits
Preventive Care Covered at 100%
Primary Care Visit Visit $15 copay (18+); $0 copay (through age 17)
Specialist Visit $15 copay per visit
Chiropractic Services (max 12 visits) $20 copay per visit
Hospital Services
Inpatient 20% after deductible
Emergency Room 20% after deductible
Urgent Care $15 copay per visit
Outpatient Services
X-Ray and Lab Tests $15 copay/day; specialty 20%
Surgery $35 copay
Prescription Drugs
Generic $10 copay ($3 OTC)
Formulary/Brand $45 copay
Specialty $200 copay
Base DPPO Buy-Up DPPO
In/Out-of-Network In/Out-of-Network
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar Year Maximum
$1,000 $2,500
Coinsurance
Preventive Covered at 100% Covered at 100%
Basic 20% after deductible 10% after deductible
Major 50% after deductible 40% after deductible
Orthodontia
OON Reimbursement 90th UCR 90th UCR
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $1,000 $1,500
Benefit Applies to Children Children
Base DPPO
Weekly Bi-Weekly Monthly
Employee $2.80 $5.60 $12.13
Employee + Spouse $5.89 $11.79 $25.54
Employee + Children $5.51 $11.03 $23.89
Family $9.08 $18.16 $39.36
Buy-Up DPPO
Weekly Bi-Weekly Monthly
Employee $5.89 $11.78 $25.53
Employee + Spouse $12.63 $25.26 $54.74
Employee + Children $10.98 $21.96 $47.58
Family $18.48 $36.95 $80.07
Coverage Level You Pay Accident Only You Pay Additional Hospital Benefit Rider
Employee $13.10 $36.94
Employee + Spouse $22.29 $78.57
Employee + Children $24.93 $78.09
Family $33.83 $114.70
Option(s) of $10,000, $15,000, or $20,000* of Coverage
Age Employee Monthly per $1,000 Spouse Monthly per $1,000 (based off employee’s age)
Under 24 $0.348 $0.348
25-29 $0.474 $0.474
30-34 $0.599 $0.599
35-39 $0.804 $0.804
40-44 $1.207 $1.207
45-49 $1.867 $1.867
50-54 $2.658 $2.658
55-59 $3.606 $3.606
60-64 $5.155 $5.155
65-69 $7.273 $7.273
70+ $7.369 $7.369
Child(ren) monthly rate per $1,000 of coverage $0.573