Small Group Health Insurance (2-50 employees) - California
This page gives you immediate access to small group health insurance plans, plan descriptions, forms, applications, rate guides, raf, underwriting guidelines, employer handbooks, group admin manuals, dental, vision, life, disibility and other specialty product information from all of the major health insurance carriers in California.
Group Medical Carriers (CA):
 Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  HSA California  |  Kaiser  |  Kaiser Choice Solution  |  Sharp  |  UHC / PacifiCare  |  Western Health Advantage
Dental Carriers (CA):
 Aetna  |  Anthem Blue Cross  |  Blue Shield  |  New Dental Choice  |  PacifiCare  |  Premier Access  |  UHC
Disability Carriers (CA):
 American Fidelity  |  The Hartford  |  The Standard  |  Unum
HSA Administration (CA):
 First Horizon  |  Health Equity  |  HSA Bank  |  Sterling HSA
Life Carriers (CA):
 Aetna  |  American Fidelity  |  Anthem Blue Cross  |  Blue Shield  |  The Hartford  |  The Standard  |  UHC  |  Unum
Specialty Products (CA):
 Ceridian  |  coPower  |  Satori
Supplemental & Voluntary (CA):
 Aflac  |  American Fidelity  |  Colonial
Vision Carriers (CA):
 Aetna  |  Anthem Blue Cross  |  Blue Shield  |  UHC  |  VSP
Wellness At Work (CA):
 My Wellchoice+
Rate Guide   Effective: 7-1-2010 to 9-30-2010    
Applications & Forms.....     Group Medical                Dental                Life Insurance                Vision
Group Admin Manual:
Underwriting Guidelines:
Employer Handbook:
Aetna PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

MC HSA HDHP $2000 80/50

5-2010
PPO
2000 indiv /
4000 family

embedded aggregate
3500 indiv /
10000 family

$5 million per member's lifetime.
(In/Out combined)
20% co-insurance AD
$20
$40
Integrated with medical ded
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
MC HSA HDHP $2500 80/50

1-2010
PPO
2500 indiv /
5000 family

embedded aggregate
4200 indiv /
8400 family

$5 million per member's lifetime.
(In/Out combined)
20% co-insurance AD
$20
$40
Integrated with medical ded
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
MC HSA HDHP $3000 100/50

4-09
PPO
3000 indiv /
6000 family

embedded aggregate

4000 indiv /
8000 family

$5 million per member's lifetime.
(In/Out combined)

0% co-insurance AD
$20
$40
Integrated with medical ded
0%
0% / $0
0% / $0
AD
MC HSA HDHP $3300 80/50

1-2010
PPO
3300 indiv /
6600 family

embedded aggregate
5000 indiv /
10000 family

$5 million per member's lifetime.
(In/Out combined)
20% co-insurance AD
$20
$40
Integrated with Medical Deductible
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
MC HRA HDHP $3000 80/50



This plan is approved for Benelect HRA Funding.
1-2010
PPO
3000 indiv /
6000 fam
4500 indiv /
9000 family

$5 million per member's lifetime.
(In/Out combined)
$20 copay deductible waived
$20
$40
Integrated with Medical Deductible
20%
20% / $0
20% / $0
AD
MC HRA HDHP $5000 80/50



This plan is approved for Benelect HRA Funding.
5-2010
PPO
3000 indiv /
6000 fam
4500 indiv /
9000 family

$5 million per member's lifetime.
(In/Out combined)
$20 copay deductible waived
$20
$40
Integrated with Medical Deductible
20%
20% / $0
20% / $0
AD
EPO $500 80 (Open Access)
5-2010
PPO
500 / 1000
5500 indiv /
2 member max

$5 millioin per member's lifetime
$25 copay
AD
$15
$40
AD
20% AD

20% AD / $0

0% / $300 AD outpatient hospital department.
0% / $100 freestanding surgical facility

EPO 80 (Open Access)

Discontinued as of 5-1-2010

4-09
PPO
0 / 0
4000 indiv /
2 member max

$5 millioin per member's lifetime. (In only)
$20 copay
$15
$40
20%

20% / $0

0% / $300 outpatient hospital department.
0% / $100 freestanding surgical facility

MC HSA HDHP $2300 80/50

Discontinued as of 2-2010
4-09
PPO
2300 indiv /
4600 family

embedded aggregate
4000 indiv /
8000 family

$5 million per member's lifetime.
(In/Out combined)
20% co-insurance AD
$20
$40
Integrated with medical ded
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
Aetna PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
MC 10000 100/50
4-09
PPO
10000 indiv /
10000 family
10000 / 10000

$5 million per member's lifetime.
(In/Out combined)
$15 copay deductible waived
$20
$40
AD
0%
0% / $0
0% / $0
AD
MC 3500 65/50
5-2010
PPO
3500 indiv /
2 mem max
8500 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$35 copay deductible waived
$20
$40
$250 ded
35% AD

35% AD / $0

35% AD / $0 outpatient hospital department.
35% AD / $0 freestanding surgical facility
MC 2500 75/50
5-2010
PPO
2500 indiv /
2 mem max
7500 indiv /
2 mem max

$5 million per member's lifetime.
(In/Out combined)
$25 copay deductible waived
$20
$40
$250 ded
25%
25% / $0
25% / $0
AD
MC $2000 80/50/50
4-09
PPO
2000 indiv /
2 mem max
7000 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$25 copay deductible waived
$15
$40
AD
20% AD

20% Professional, 50% Facility AD / $0

30% Professional, 50% Facility AD / $0 outpatient hospital department.
20% Professional, 50% Facility AD / $0 freestanding surgical facility
MC $1000 70/50
4-09
PPO
1000 indiv /
2 mem max
6000 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$25 copay deductible waived
$15 /
$40 /
AD
30% AD

30% AD / $0

40% AD / $150 outpatient hospital department.
30% AD / $0 freestanding surgical facility
MC $1000 80/50/50
4-09
PPO
1000 indiv /
2 mem max
6000 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$25 copay deductible waived
$15
$40
AD
20% AD

20% Professional, 50% Facility AD / $0

30% Professional, 50% Facility AD / $0 outpatient hospital department.
20% Professional, 50% Facility AD / $0 freestanding surgical facility
Aetna PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
PPO $750 80/60
4-09
PPO
750 indiv /
2 mem max
5250 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$25 copay deductible waived
$15
$40
AD
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
MC $750 80/50/50
4-09
PPO
750 indiv /
2 mem max
5750 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$25 copay deductible waived
$15
$40
AD
20% AD

20% Professional, 50% Facility AD / $0

30% Professional, 50% Facility AD / $0 outpatient hospital department.
20% Professional, 50% Facility AD / $0 freestanding surgical facility
MC $500 80/60
4-09
PPO
500 indiv /
2 mem max
4500 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$35 copay deductible waived
$15
$40
AD
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
PPO $500 90/70
4-09
PPO
500 indiv /
2 mem max
4500 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)

$15 copay deductible waived
$15
$40
AD
10% AD

10% AD / $250

20% AD / $150 outpatient hospital department.
10% AD / $0 freestanding surgical facility
MC $250 80/60
4-09
PPO
250 indiv /
2 mem max
3750 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)
$20 copay deductible waived
$15
$40
AD
20% AD

20% AD / $0

30% AD / $0 outpatient hospital department.
20% AD / $0 freestanding surgical facility
MC $250 90/70
4-09
PPO
250 indiv /
2 mem max
3250 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)
$15 copay deductible waived
$10
$25
AD
10% AD

10% AD / $0

20% AD / $0 outpatient hospital department.
10% AD / $0 freestanding surgical facility

MC Basic

Discontinued as of 5-1-2010

4-09
PPO
2000 indiv /
2 mem max
5000 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)
$20 copay deductible waived
$15
50% copay
AD
20% AD

20% AD / $0

30% AD / $150 outpatient hospital department.
20% AD / $0 freestanding surgical facility
Indemnity
4-09
PPO
500 indiv /
2 mem max
4000 indiv /
2 member max

$5 million per member's lifetime.
(In/Out combined)
20% co-insurance after deductible
$10
$25
150 $ded
20% AD

20% AD / $250

30% AD / $250 outpatient hospital department.
20% AD / $0 freestanding surgical facility
Aetna HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

HMO HRA $1500

Discontinued as of 5-1-2010
4-08
HMO
1500 indiv / 3000 family
3500 indiv /
7000 family

Unlimited Lifetime Max except where otherwise indicated.
$40 copay deductible waived
$20
$40
$0 ded
0%

0% / $500 AD

0% / $250 AD outpatient hospital department.
0% / $125 AD freestanding surgical facility

HMO HRA $750

Discontinued as of 5-1-2010

4-08
HMO
750 indiv / 1500 family
2000 indiv /
4000 family

Unlimited Lifetime Max except where otherwise indicated.
$25 copay deductible waived
$20
$40
AD
0%

0% / $250 AD

0% / $200 AD outpatient hospital department.
0% / $100 AD freestanding surgical facility
HMO Deductible



This plan is approved for Benelect HRA Funding.
4-08
HMO
1000 indiv /
2000 family
3500 indiv /
7000 family

Unlimited Lifetime Max except where otherwise indicated.
$40 copay deductible waived
$20
$40
$0 ded
30% AD

30% AD / $0

30% AD / $0 outpatient hospital department.
30% AD / $0 freestanding surgical facility
HMO $50
5-2010
HMO
0 / 0
4000 indiv /
8000 family

Unlimited Lifetime Max except where otherwise indicated
$50 copay
$15 /
$35 /
$0 ded
0%

0% / $1000 per day up to 3 days per admit

0% / $500 outpatient hospital facility.
0% / $250 performed other than a hospital outpatient facility
HMO $40
4-09
HMO
0 / 0
3500 indiv /
7000 family

Unlimited Lifetime Max except where otherwise indicated
$40 copay
$15 /
$35 /
$0 ded
0%

0% / $750 per day up to 3 days per admit

0% / $400 outpatient hospital facility.
0% / $200 performed other than a hospital outpatient facility
HMO $30
4-09
HMO
0 / 0
3000 indiv /
6000 family

Unlimited Lifetime Max except where otherwise indicated
$30 copay
$15
$35
$0 ded
0%

0% / $500 per day up to 3 days per admit

0% / $300 outpatient hospital facility.
0% / $150 performed other than a hospital outpatient facility
HMO $20
4-09
HMO
0 / 0
2500 indiv /
5000 family

Unlimited Lifetime Max except where otherwise indicated
$20 copay
$15
$35
$0 ded
0%

0% / $200 per day up to 3 days per admit

0% / $250 outpatient hospital facility.
0% / $100 performed other than a hospital outpatient facility
Aetna HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

HMO $15

Discontinued as of 5-1-2010

4-09
HMO
0 / 0
2000 indiv /
4000 family

Unlimited Lifetime Max except where otherwise indicated
$15 copay
$15
$35
$0 ded
0%

0% / $150 per day up to 3 days per admit

0% / $250 outpatient hospital facility.
0% / $100 performed other than a hospital outpatient facility
HMO $10
4-09
HMO
0 / 0
1500 indiv /
3000 family

Unlimited Lifetime Max except where otherwise indicated
$10 copay
$15
$35
$0 ded
0%

0% / $0 per day up to 3 days per admit

0% / $100 outpatient hospital facility.
0% / $0 performed other than a hospital outpatient facility
Value Network* HMO $40/$50
5-2010
HMO
0 / 0
3500 indiv /
7000 family

Unlimited Lifetime Max except where otherwise indicated
$40 copay
$20
$40
$0 ded
0%

0% / $800 per day up to 3 days per admit

0% / $400 outpatient hospital facility.
0% / $200 performed other than a hospital outpatient facility
Value Network* HMO $30/$40
5-2010
HMO
0 / 0
3000 indiv /
6000 family

Unlimited Lifetime Max except where otherwise indicated
$30 copay
$20
$40
$0 ded
0%

0% / $600 per day up to 3 days per admit

0% / $300 outpatient hospital facility.
0% / $150 performed other than a hospital outpatient facility
Value Network* HMO $20/$30
5-2010
HMO
0 / 0
2500 indiv /
5000 family

Unlimited Lifetime Max except where otherwise indicated
$20 copay
$20
$40
$0 ded
0%

0% / $400 per day up to 3 days per admit

0% / $200 outpatient hospital facility.
0% / $100 performed other than a hospital outpatient facility
Value Network* HMO $10/$20
5-2010
HMO
0 / 0
2000 indiv /
4000 family

Unlimited Lifetime Max except where otherwise indicated
$10 copay
$20
$40
$0 ded
0%

0% / $100 per day up to 3 days per admit

0% / $100 outpatient hospital facility.
0% / $0 performed other than a hospital outpatient facility
Vitalidad HMO $5
4-08
HMO
0 / 0
1500 indiv /
3000 family

Unlimited Lifetime Max
$5 copay
$5
$5
0 $ded
0%
0% / $0
0% / $0
Vitalidad HMO $10
4-08
HMO
0 / 0
2000 indiv /
4000 family

Unlimited Lifetime Max
$0
$10
$10
0 $ded
0%

0% / $100 per day up to $700 per admit

0% / $0
Vitalidad Plus California con Aetna HMO $40/$10

5-2010
HMO
0 / 0
3500 indiv /
7000 family

Unlimited Lifetime Max
$40 copay
$15
$35
$0 ded
0%

0% / $800 per day up to 3 days per admit

0% / $400 outpatient hospital facility.
0% / $200 performed in a freestanding facility
Vitalidad Plus California con Aetna HMO $30/$10
5-2010
HMO
0 / 0
3000 indiv /
6000 family

Unlimited Lifetime Max
$30 copay
$15
$35
$0 ded
0%

0% / $600 per day up to 3 days per admit

0% / $300 outpatient hospital facility.
0% / $150 performed in a freestanding facility
Vitalidad Plus California con Aetna HMO $20/$5
5-2010
HMO
0 / 0
2500 indiv /
5000 family

Unlimited Lifetime Max
$20 copay
$15
$35
0 $ded
0%

0% / $400 per day up to 3 days per admit

0% / $200 outpatient hospital facility.
0% / $100 performed in a freestanding facility
Vitalidad Plus California con Aetna HMO $10/$5
5-2010
HMO
0 / 0
2000 indiv /
4000 family

Unlimited Lifetime Max
$10 copay
$15
$35
$0 ded
0%

0% / $100 per day up to 3 days per admit

0% / $100 outpatient hospital facility.
0% / $50 performed in a freestanding facility
Aetna HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
VIEW DISCONTINUED AETNA PLANS - CLICK HERE view / hide Aetna Details
Rate Guide   Effective: 7-1-2010 to 9-30-2010  

Applications & Forms.....     Group Medical                Dental                Life Insurance                Vision
Provider Networks:      California      National
Group Admin Manual:
Underwriting Guidelines:
Employer Handbook:
Blue Cross PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Lumenos HSA 5000 (100/70)
7-09
PPO
5000 / 10000
aggregate
5800 / 11600
aggregate

5 million per member
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 3500 (80/50)
7-09
PPO
3500 / 7000
aggregate
5000 / 10000
aggregate

5 million per member
20% co-ins
AD
$10
$30
AD
20%
20% / $0
20% / $0
AD
Lumenos HSA 3000 (100/70)
7-09
PPO
3000 / 6000
aggregate
5000 / 10000
aggregate

5 million
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 2500 (80/50)
7-09
PPO
2500 / 5000
aggregate
5000 / 10000
aggregate

5 million per member
20% co-ins
AD
$10
$30
AD
20%
20% / $0
20% / $0
AD
Lumenos HSA 2000 (100/70)
7-09
PPO
2000 / 4000
aggregate
4000 / 8000
aggregate

5 million
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 1500 (80/50)
7-09
PPO
1500 / 3000
aggregate
3000 / 6000
aggregate

5 million per member
20% co-ins
AD
$10
$30
AD
20%
20% / $0
20% / $0
AD
Lumenos HSA 1500 (100/70)
7-09
PPO
1500 / 3000
aggregate
3000 / 6000
aggregate

5 million per member
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos® HIA Plus 500
7-09
PPO
2000 / 4000
aggregate (Allocation amounts apply to ded)

Health Incentive Plan Allocation
500 / 1000 aggregate
5000 / 10000
aggregate

5 million per member

40% co-ins
AD
$10
$30
AD
40%
40% / $0
40% / $0
AD
Lumenos® HIA Plus 750
7-09
PPO
1500 / 3000 aggregate
(Allocation amounts apply to ded)

Health Incentive Plan Allocation
750 / 1500 aggregate
5000 / 10000 aggregate

5 million per member

25% co-ins
AD
$10
$30
AD
25%
25% / $0
25% / $0
AD
Lumenos® HIA Plus 3000
7-09
PPO
3000 / 6000 aggregate
(Allocation amounts apply to ded)

Health Incentive Plan Allocation
1000 / 2000 aggregate
3000 / 6000 aggregate

5 million

0% co-ins
AD
0%
0%
AD
0%
0% / $0
0% / $0
AD
PPO 3500 HSA-Compatible
7-09
PPO
3500 / 7000
aggregate

4000 / 7500
aggregate

5 million
$35 copay
AD
$10
$25
AD
0%
0% / $0
0% / $0
AD
PPO 2400 HSA-Compatible
2-08
PPO
2400 / 4800
aggregate

3600 / 5500
aggregate

5 million

$35 copay
AD
$10
$25
AD
20%
20% / $0
20% / $0
AD
High Deductible EPO



This plan is approved for Benelect HRA Funding.
2-08
PPO
2000 / 4000
aggregate

3100 / 5700
aggregate

5 million
20% co-ins
AD
$10
$25
AD
20%
20% / $0
20% / $0
AD
Blue Cross PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Solution 2500 PPO
7-09
PPO
2500 per person - 2 person max
5000 per person - 2 person max

5 million
$25 copay
$10
$25
250 $ded
25%
25% / $0
25% / $0
AD
Solution 3500 PPO
7-09
PPO
3500 per person - 2 person max
5000 per person - 2 person max

5 million
$35 copay
$10
$35
250 $ded
35%
35% / $0
35% / $0
AD
Solution 5000 PPO
7-09
PPO
5000 per person - 2 person max
7500 per person - 2 person max

5 million
$40 copay
$10
$35
250 $ded
40%
40% / $0
40% / $0
AD
Saver PPO Plan
7-09
PPO
5500 / 11000
7000 / 14000

5 million
2 visits /
$20 copay
$10

$25 if gen not avail OR $10 + difference in cost between gen and brand if gen is available

AD
20%
20% / $0
20% / $0
After $500 ded
Basic PPO Plan
7-09
PPO
1250 / 2500
3250 / 6500

5 million
not covered

$10 /

$25 if gen not avail OR $10 + difference in cost between gen and brand if gen is avail

AD
20%
20% / $0
20% / $0
AD
PPO $40 Copay
7-09
PPO
750 / two-member max
4500 / 9000

5 million
40 copay
$10
$30
$150 ded
40%
40% / $0
40% / $0
AD
PPO $30 Copay
7-09
PPO
500 / 1000
4000 / 8000

5 million
$30 copay
$10
$30
150 $ded
30%
30% / $0
30% / $0
AD
PPO $20 Copay
7-09
PPO
250 / 500
3500 / 7000

5 million
$20 copay
$10
$30
150 $ded
20%
20% / $0
20% / $0
AD
Blue Cross PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
PPO $45 Copay GenRx*
7-09
PPO
750 / 1500
4500 / 9000

5 million
$45 copay
$10
na
$0 ded
45%
45% / $0
45% / $0
AD
PPO $35 Copay GenRx*
7-09
PPO
500 / 1000
4000 / 8000

5 million
$35 copay
$10
na
0 $ded
35%
35% / $0
35% / $0
AD
PPO $25 Copay GenRx*
7-09
PPO
250 / 500
3500 / 7000

5 million
$25 copay
$10
na
0 $ded
25%
25% / $0
25% / $0
AD
Advantage $25 Copay*
7-09
PPO
250 / 500
3600 / 7200

5 million
12 visits / $25 copay /
45% co-ins up to $900 and then 10% co-insurance from $901 to $3,600
$15

$25 if gen not avail OR $15 + difference in cost between gen and brand if gen is avail

AD
30% up to $900, 10% from $901 to $3600

30% up to $900, 10% from $901 to $3600 / $0

30% up to $900, 10% from $901 to $3600 / $0
Premier $30 Copay
7-09
PPO
500 / 1000
3500 per mem / two-mem max

5 million
$30 copay
$10
$25
$0 ded
30%
30% / $0
30% / $0
AD
Premier $20 Copay
7-09
PPO
250 / 500

3000 per mem / two-mem max

5 million
$20 copay
$10
$25
$0 ded
20%
20% / $0
20% / $0
AD
Premier $10 Copay
7-09
PPO
250 / 500

2500 / 5000

5 million
$10 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
AD
Power Healthfund 750*
7-09
PPO

500 / 1000

First Dollar Coverage
750 / 1500

5000 / 10000

5 million
$35 copay
$10

$30 if gen not avail OR $10 + difference in cost between gen and brand if gen is avail

$250 ded
25%
25% / $0
25% / $0
AD
(when First Dollar Coverage is used up)
Blue Cross PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Power Healthfund 500*
7-09
PPO

1000 / 2000
aggregate

First Dollar Coverage
$500 / $1000

5000 / 10000
aggregate

5 million

$40 copay
$10

$35 if gen not avail OR $10 + difference in cost between gen and brand if gen is avail

$350 ded
40%
40% / $0
40% / $0
AD
(When First Dollar Coverage is used up)
Hospital BeneFits Preferred
Overview of changes
2-07
7-09
PPO
750 / 1500

3250 / 6500

5 million

50% co-ins up to a max benefit of $750 per calendar year per member

$15
na
no ded
30%
30% / $0
30% / $0
AD
Hospital BeneFits Plus - 2-07
Overview of changes - 7-09
2-07
7-09
PPO
1000 / 2000

3500 / 7000

5 million
50% co-ins
$15
na
0 $ded
30%
30% / $0
50% / $0
AD
Hospital BeneFits - 2-07
Overview of changes - 7-09
2-07
7-09
PPO
1250 / 2500

3750 / 7500

5 million

100% co-ins
$15
na
0 $ded
30%
30% / $0
50% / $0
AD
Elements Hospital

7-09
PPO
1250 / 2500

3750 / 7500

5 million
na
$10
na
AD
30%
30% / $0
30% / $0
AD
Elements Hospital Plus

7-09
PPO
1000 / 2000

3500 / 7000

5 million
50% co-ins for first $1000. Max Anthem payment of $500 per member, per year, in/out combined.
$10
na
AD
30%
30% / $0
30% / $0
AD
Elements Hospital Preferred

7-09
PPO
750 / 1500

3250 / 6500

5 million
50% co-ins for first $1500. Max Anthem payment of $750 per member, per year, in/out combined.
$10
$35
$250 ded
20%
20% / $0
20% / $0
Blue Cross HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Select 25 HMO
7-09
HMO
500 per member

2250 / 4500 aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$25 copay
$10
$25
$150 ded
0%
0% / $0
20% / $0
AD
Select 35 HMO
7-09
HMO
1000 per member

3000 / 6000
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$35 copay
$10
$25
150 $ded
0%
0% / $0
30% / $0
AD
Saver 20 HMO
7-09
HMO
1500 per member

2250 / 4500
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)
$20 copay
$10
$25
$150 ded
0%
0% / $0
0% / $0
AD
Saver 30 HMO
7-09
HMO
2500 per member

3000 / 6000
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)
$30 copay
$10
$25
$150 ded
0%
0% / $0
0% / $0
AD
Saver 40 HMO
7-09
HMO
3500 per member

4000 / 8000
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$40 copay
$10
$25
250 $ded
0%
0% / $0
0% / $0
AD
Classic 20 HMO
7-09
HMO
0

1750 / 3500
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$20 copay
$10
$25
$150 ded
0%
0% / $0
20% / $0
AD
Blue Cross HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Classic 30 HMO
7-09
HMO
0

2500 / 5000
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$30 copay
$10
$25
$150 ded
0%
0% / $0
20% / $0
AD
Classic 40 HMO
7-09
HMO
0

3500 / 7000
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$40 copay
$10
$25
$250 ded
0%
0% / $0
30% / $0
AD
HMO $25 100%
7-09
HMO
0

1750 / 3500
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$25 copay
$10
$25
$150 ded
0%
0% / $0
0% / $0
AD
HMO $10 100%
7-09
HMO
0

1750 / 3500
aggregate

Unlimited Lifetime Max (in network only, unless medical emergency)

$10 copay
$10
$25
$150 ded
0%
0% / $0
0% / $0
AD
Blue Cross HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
VIEW DISCONTINUED ANTHEM BLUE CROSS PLANS - CLICK HERE view / hide Anthem Blue Cross Details
Rate Guide   Eff: 7-2010 to 9-30-10    
Applications & Forms.....     Group Medical                Dental                Life Insurance                Vision
Provider Networks:      California      National
Group Admin Manual:
Underwriting Guidelines:
Employer Handbook:
Benefit Summary Guide:
Plans-at-a-Glance for Suite Deal plans:
Plan Comparison Guide:
Blue Shield PPO/HSA Plans
Effective
Network
In-Network
Ded Sgl/Fam

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Shield Savings 4800
7-2010
PPO
HSA
4800 / 9600
embedded

5900 indiv /
11800 family
embedded

6 Million
0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 2500
7-2010
PPO
HSA
2500 / 5000
embedded

4000 / 8000
embedded

6 million
20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings 3000/6000

7-2010
PPO
HSA
3000 / 6000

4500 / 9000

6 million
0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 2250/4500



This plan is approved for Benelect HRA Funding.
7-2010
PPO
HSA
2250 / 4500

4500 / 9000

6 million
20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings 2000/4000
7-2010
PPO
HSA
2000 / 4000

3500 / 7000

6 million
0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 1800/3600



This plan is approved for Benelect HRA Funding.
7-2010
PPO
HSA
1800 / 3600

3000 / 6000

6 million
0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings QS 4800

7-2010
PPO
HSA
4800 /9600

5900 / 11800

6 million
20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings QS 3000/6000

7-2010
PPO
HSA
3000 / 6000

4500 / 9000

6 million
20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings QS 2000/4000

7-2010
PPO
HSA
2000 / 4000

3500 / 7000

6 million
20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Blue Shield PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Shield Spectrum PPO Plan 3000



This plan is approved for Benelect HRA Funding.
7-2010
PPO
3000 / 6000

9000 / 18000

6 million
20% co-ins
$15
$30 or 30%
$500 ded
20%
20% / $0
20% / $250 surgery
AD
Shield Spectrum PPO Plan 2000 Value
7-2010
PPO
2000 per member

7000 per member

6 million

2 visits / $40 copay /
after 2 visits 100% co-ins until max copay has been met - then 0% co-ins
$15
n/a
35%
35% / $0
35% / $500 surgery
AD
Shield Spectrum PPO Plan 1500 Value
7-2010
PPO
1500 per member

6000 per member

6 million

3 visits / $30 copay /
after 3 visits 100% co-ins until max ded has been met - then 30% co-ins

$15
$30 or 30%
$0 ded
$500 brand name coverage max per member per calendar year

30%
30% / $0
30% / $500 surgery
AD
Shield Spectrum PPO Plan 1000
7-2010
PPO
1000 / 2000

6000 / 12000

6 million
$45 copay
$10
$30
$250 ded
25%
25% / $0
25% / $500 surgery
AD
Shield Spectrum PPO Plan 1000 Value
7-2010
PPO
1000 per member

5000 per member

6 million
3 visits / $20 copay /
after 3 visits 100% co-ins until max ded has been met - then 30% co-ins
$15
$30 or 30%
0 $ded
$1000 brand name coverage max per member per calendar year
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 750 Value
7-2010
PPO
750 per member

4750 per member

6 million
3 visits / $15 copay /
after 3 visits 100% co-ins until max ded has been met - then 30% co-ins
$15
$30 or 30%
250 $ded
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 500 Premier
7-2010
PPO
500 / 1000

4000 / 8000

6 million
$35 copay
$10
$30
$150 ded
20%
20% / $0
20% / $150 surgery
AD
Blue Shield PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Shield Spectrum Plan 500 Standard
7-2010
PPO
500 / 1000

4500 / 9000

6 million
$40 copay
$10
$30
250 $ded
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 500 Value
7-2010
PPO
500 indiv / 1000 2 pers / 1500 family

5500 per mem /
11000 2 pers /
16500 family

6 million
$45 copay
$15
$30 or 30%
$250 ded
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 250 Premier
7-2010
PPO
250 / 500

2750 indiv /
5500 family

6 million
$15 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
AD
Shield Spectrum PPO Plan 250 Standard
7-2010
PPO
250 / 500

3250 / 6500

6 million
$25 copay
$10
$30
0 $ded
20%
20% / $0
20% / $0
AD
Shield Spectrum PPO Plan, Zero Deductible
7-2010
PPO
0 / 0

2000 / 4000

6 million
$10 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
Active Choice Plan 750 SG
7-2010
PPO

0 / 0

First Dollar Coverage
$750 / $1500
5000 / 10000
100% co-ins up to max copay then many benefits will be 0% co-ins
$15
$30 or 30%
$250 ded
20%
20% / $0
20% / $0
Active Choice Plan 500 SG
7-2010
PPO

0 / 0

First Dollar Service
$500 / $1000
5000 / 10000
100% co-ins up to max copay then many benefits will be 0% co-ins
$15
$30 or 30%
$500 ded
30%
30% / $0
30% / $0
Blue Shield POS Plans
Effective
Network
In-Network
Ded Sgl/Fam

In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Added Advantage POS Plan
7-2010
POS
0 / 0

2500 / 5000

None
$25 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Blue Shield HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Access+ HMO Plan 40
7-2010
HMO
0 / 0

4000 / 8000

None

$40 copay
$15
$30
250 $ded
0%
0% / $0
40% / $0
Access+ HMO Plan 30
7-2010
HMO
0 / 0

3500 / 7000

None
$30 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access+ HMO Plan 25
7-2010
HMO
0 / 0

3500 / 7000

None
$25 copay
$15
$30
$250 ded
0%
0% / $0
25% / $0
Access+ HMO Plan 20
7-2010
HMO
0 / 0

2500 / 5000

None
$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access+ HMO Plan 20 Value
7-2010
HMO
0 / 0

3000 / 6000

None
$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Blue Shield HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Access+ HMO Plan 15
7-2010
HMO
0 / 0

2000 / 4000

None
$15 copay
$15
$30
0 $ded
0%
0% / $0
0% / $250 surgery
Access+ HMO Plan 10
7-2010
HMO
0 / 0
2000 / 4000

None
$10 copay
$10
$25
0 $ded
0%
0% / $0
0% / $50 surgery
Access+ HMO Plan 5
7-2010
HMO
0 / 0

1500 / 3000

None
$5 copay
$10
$25
0 $ded
0%
0% / $0
0% / $0
Local Access+ HMO Plan 30
7-2010
HMO
0 / 0

3500 / 7000

None
$30 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Local Access+ HMO Plan 20 Value

1-2010
HMO
0 / 0

3000 / 6000

None
$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access Baja® HMO Plan 10
7-2010
HMO
0 / 0

1000 / 2000

None
$10 copay
$10
$10
0 $ded
0%
0% / $0
0% / $50
Access Baja® HMO Plan 5
7-2010
HMO
0 / 0
1000 / 2000

None
$5 copay
$5
$5
0 $ded
0%
0% / $0
0% / $25
Blue Shield HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
VIEW DISCONTINUED BLUE SHIELD PLANS - CLICK HERE view / hide Blue Shield Details
Rate Guide   Effective: 7-2010 to 12-2010    
Applications & Forms.....     Group Medical
Provider Networks N/A
Group Admin Manual: Underwriting Guidelines:
Employer Handbook:
California Choice PPO Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

CalChoice PPO 750

 
1-2010
PPO
750 / 2250
aggregate
3750 indiv /
7500 family

6 Million
$35 copay
$15
$30
150 $ded
20%
20% / $500
20% / $500
CalChoice PPO 1000
1-2010
PPO
1000 / 3000
aggregate
4000 indiv/
8000 family

6 Million
$35 copay
$15
$30
200 $ded
30%
30% / $1000
30% / $500
CalChoice PPO 2400
1-2010
PPO
2400 / 7200
aggregate
5000 indiv /
10000 family
$40 copay
$15
$30
250 $ded
0%
30% / $500
30% / $500
California Choice Active Choice & HSA Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Active Choice 500
1-2010
PPO
0 / 0
5000 / 10000

First Dollar Coverage
$500 / $1000

6 Million
0% up to
$500 ind / $1,000 family
$15
$30
$500 ded
25%
25% / $500
25% / $400
CalChoice HSA 1500
1-2010
HSA
1500 / 3000
aggregate
2800 / 5600

6 Million
20%
AD
$15
$30
AD
20%
20% / $0
20% / $0
AD
CalChoice HSA 2400
1-2010
HSA
2400 / 4800
aggregate
3200 / 5800

6 Million
20%
AD
$15
$30
AD
20%
20% / $0
20% / $0
AD
CalChoice HSA 2500 (3V7)

Participating Health Plans: Health Net
7-09
HSA
2500 / 5000
5000 / 10000

5 Million
$25
AD
$15
$30
AD
30%
30% / $0
30% / $0
AD
CalChoice HSA 3500 (3V6)

Participating Health Plans: Health Net
7-09
HSA
3500 / 7000
5000 / 10000

5 Million
$35
AD
$15
$30
AD
30%
30% / $0
30% / $0
AD
CalChoice HSA 4500 (3V5)

Participating Health Plans: Health Net
7-09
HSA
4500 / 9000
5600 / 11200

5 Million
$45
AD
$15
$30
AD
40%
40% / $0
40% / $0
AD
California Choice EOA Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

Elect Open Access

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
2500 indiv /
6000 family
$25 copay HMO /
$40 copay PPO
$15
$30
150 $ded
25%
25% / $0
25% / $0

EOA 25 (92H)

Participating Health Plans: Health Net
7-09
HMO
0 / 0
2500 indiv /
6000 family
$25 copay HMO /
$40 copay PPO
$15
$30
150 $ded
25%
25% / $0
25% / $0
California Choice HMO Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

CalChoice HMO 15

Participating Health Plans: Blue Shield, Health Net, Kaiser Permanente, Sharp, Western Health Advantage
1-2010
HMO
0 / 0
2000 indiv /
4000 family
$15 copay
$10
$20
0 $ded
0%
0% / $400
0% / $200

CalChoice HMO 25

Participating Health Plans: Blue Shield, Sharp, Western Health Advantage
1-2010
HMO
0 / 0
2500 indiv /
5000 family
$25 copay
$15
$30
100 $ded
0%

0% / $400 per day, max $1200

0% / $300

CalChoice HMO 25

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
3000 indiv /
6000 family
$25 copay
$15
$30
100 $ded
0%

0% / $450 per day, max $1800

0% / $400

CalChoice HMO 25

Participating Health Plans: Kaiser Permanente
1-2010
HMO
0 / 0
2500 indiv /
5000 family
$25 copay
$10
$25
0 $ded
0%
0% / $400
0% / $300

CalChoice HMO 25 Value

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
3000 indiv /
6000 family
$25 copay
$15
$30
100 $ded
25%
25% / $0
25% / $0

CalChoice HMO 25 Value

Participating Health Plans: Blue Shield
1-2010
HMO
1000 / 2000
3000 indiv /
6000 family
$25 copay
$15
$30
200 $ded
0% AD

0% / $400 per day AD, max $1600

0% / $400 AD

Salud HMO y mas

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
2500 indiv /
5000 family
$25 copay
$15
$25
0 $ded
0%

0% / $500 per day, max $1000

0% / $300
California Choice HMO Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

CalChoice HMO 30

Participating Health Plans: Blue Shield, Health Net, Sharp, Western Health Advantage
1-2010
HMO
0 / 0
3000 indiv /
6000 family
$30 copay
$15
$30
150 $ded
0%

0% / $450 per day, max $1800

0% / $400

CalChoice HMO 30

Participating Health Plans: Kaiser Permanente
1-2010
HMO
0 / 0
3000 indiv /
6000 family
$30 copay
$15
$30
0 $ded
0%
0% / $450
0% / $400

CalChoice HMO 30 Value

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
3500 indiv /
7000 family
$30 copay
$20
$30
200 $ded
30%
30% / $0
30% / $0

CalChoice HMO 40

Participating Health Plans: Blue Shield, Health Net, Sharp, Western Health Advantage
1-2010
HMO
0 / 0
3500 indiv /
7000 family
$40 copay
$20
$30
200 $ded
0%

0% / $500 per day

0% / $500

CalChoice HMO 40

Participating Health Plans: Kaiser Permanente
1-2010
HMO
0 / 0
3500 indiv /
7000 family
$40 copay
$15
$30
0 $ded
0%

0% / $500 per day

0% / $500

CalChoice HMO 40 Value

Participating Health Plans: Health Net
1-2010
HMO
0 / 0
3500 indiv /
7000 family
$40 copay
$20
$30
200 $ded
40%
40% / $0
40% / $0

CalChoice HMO 40 Value

Participating Health Plans: Blue Shield
1-2010
HMO
1500 / 3000
4000 indiv /
8000 family
$40 copay
$15
$30
250 $ded
0%

0% / $750 per day AD

0% / $750 AD

CalChoice HMO 40 Value

Participating Health Plans: Western Health Advantage
1-2010
HMO
2500 / 5000
5000 indiv /
10000 family
$40 copay
$20
$30
250 $ded
0%

0% / $500 per day AD

0% / $250
California Choice HMO Plans
Effective
Network
In-Network Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
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Effective
Network
In-Network
Ded Sgl/Fam

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Health Net HSA Plans

Value HSA 4500 - Plan 9G8

 
5-2010
PPO
4500 / 9000

6000 / 12000

5 million combined with PPO and OON
$40 copay
AD
$15
$30
AD
50%

50% / $500 per calendar year

50% / $250 per calendar year
Value HSA 3500 - Plan 9G7

5-2010
PPO
3500 / 7000

5000 / 10000

5 million combined with PPO and OON
$30 copay
AD
$15
$30
AD
30% AD

30% / $250 per calendar year

30% / $250 per calendar year
Value HSA 2500 - Plan 9G6

5-2010
PPO
2500 / 5000

4000 / 8000

5 million combined with PPO and OON
$20 copay
AD
$15
$30
AD
20% AD

20% / $250 per calendar year

20% / $250 per calendar year
Value HSA 1500 - Plan 9G5

5-2010
PPO
1500 / 3000

3000 / 6000

5 million combined with PPO and OON
$10 copay
AD
$10
$25
AD
20%
20% / $0
20% / $0
AD
Standard HSA 2000 - Plan 9G2

5-2010
PPO
2000 / 4000

4000 / 8000

5 million combined with PPO and OON
0% co-ins
AD
$10
$25
AD
0%
0% / $0
0% / $0
AD
Standard HSA 3000 - Plan 9G3

5-2010
PPO
3000 / 6000

5000 / 10000

5 million combined with PPO and OON
0% co-ins
AD
$10
$25
AD
0%
0% / $0
0% / $0
AD
Standard HSA 4000 - Plan 9G4

5-2010
PPO
4000 / 8000

5950 / 11900

5 million combined with PPO and OON
0% co-ins
AD
$10
$25
AD
0%
0% / $0
0% / $0
AD
Hn Options PPO HSA 4000 - Plan 9R6

5-2010
PPO
4000 / 8000

5000 / 10000

5 million combined with PPO and OON
$35 copay
AD
$15
$30
AD
40% AD

40% / $250 per calendar year

40% / $250 per calendar year
Hn Options PPO HSA 3000 - Plan 9R5

5-2010
PPO
3000 / 6000

4000 / 8000

5 million combined with PPO and OON
$25 copay
AD
$15
$30
AD
30% AD

30% / $250 per calendar year

30% / $250 per calendar year
Health Net HRA Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
HRA 3000 - Plan 9R8



This plan is approved for Benelect HRA Funding.
5-2010
PPO
3000 / 6000

4000 / 8000

5 million combined with PPO and OON
not covered
$10
$25
AD
20%
20% / $0
20% / $0
AD
HRA 5000 - Plan 9R9



This plan is approved for Benelect HRA Funding.
5-2010
PPO
5000 / 10000

6000 / 12000

5 million combined with PPO and OON
not covered
$10
$25
AD
20%
20% / $0
20% / $0
AD
Health Net PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
PPO-40 Standard - Plan 9N4

5-2010
PPO
500 / 1000

5500 / 11000

5 million combined with PPO and OON
$40 copay
AD
$15
$30
$0 ded
40% AD

40% / $500 ded per calendar year

40% / $250 ded per calendar year
PPO - 40 Value - Plan 9N8

5-2010
PPO
1500 / 3000

6500 / 13000

5 million combined with PPO and OON
$40 copay
AD
$15
$30
$250 ded
50% AD

50% / $500 ded per calendar year

50% / $250 ded per calendar year
PPO - 30 Standard - Plan 9N7

5-2010
PPO
500 / 1000

4000 / 8000

5 million combined with PPO and OON
$30 copay
AD
$15
$30
$0 ded
20% AD

20% / $250 ded per calendar year

20% / $250 ded per calendar year
PPO - 30 Value - Plan 9R1

5-2010
PPO
1500 / 3000

6000 / 12000

5 million combined with PPO and OON
$30 copay
AD
$15
$30
$200 ded
30% AD

30% / $250 ded per calendar year

30% / $250 ded per calendar year
PPO-20 Standard - Plan 9N6

5-2010
PPO
250 / 500

3250 / 6500

5 million combined with PPO and OON
$20 copay
AD
$15
$30
0 $ded
10% AD

10% / $250 ded per calendar year

10% / $250 ded per calendar year
PPO - 20 Value - Plan 9P1

5-2010
PPO
1250 / 2500

4750 / 9500

5 million combined with PPO and OON
$20 copay
AD
$15
$30
$150 ded
20% AD

20% / $250 ded per calendar year

20% / $250 ded per calendar year
PPO-10 Standard - Plan 9N5

5-2010
PPO
0 / 0

2500 / 5000

5 million combined with PPO and OON
$10 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
PPO - 10 Value - Plan 9N9

5-2010
PPO
1000 / 2000

3500 / 7000

5 million combined with PPO and OON
$10 copay
AD
$10
$25
$100 ded
20%
20% / $0
20% / $0
AD
Health Net PPO Plans

(EOA = Elect Open Access plan)
(SN = Silver Network plan)
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Hn Options PPO 1750 - Plan 9R2

5-2010
PPO
1750 / 3500

6750 / 13500

5 million combined with PPO and OON
$35 copay
AD
$15
$30
$200 ded
40%

40% / $250 ded per calendar year

40% / $250 ded per calendar year
Hn Options PPO 1500 - Plan 9R7

5-2010
PPO
1500 / 3000

5500 / 11000

5 million combined with PPO and OON
$25 copay
AD
$15
$30
$200 ded
30%

30% / $250 ded per calendar year

30% / $250 ded per calendar year
Hn Options PPO 500 - Plan 9R4

5-2010
PPO
500 / 1000

4500 / 9000

5 million combined with PPO and OON
$35 copay
AD
$15
$30
200 $ded
30%

30% / $250 ded per calendar year

30% / $250 ded per calendar year
Hn Options PPO 250 - Plan 9R3

5-2010
PPO
250 / 500

3750 / 7500

5 million combined with PPO and OON
$25 copay
AD
$15
$30
150 $ded
20% AD

20% / $250 ded per calendar year

20% / $250 ded per calendar year
Hn OPTIONS EOA 35 - Plan 87B
SN Hn OPTIONS EOA 35 - Plan 9T6

5-2010
PPO
0 / 0

4000 / 8000

No Lifetime Max

$50 copay
$15
$30
$200 ded
30%
30% / $0
30% / $0
Hn OPTIONS EOA 25 - Plan 879
SN Hn OPTIONS EOA 25 - Plan 9T7

5-2010
PPO
0 / 0

3000 / 6000

No Lifetime Max

$40 copay

$15
$30
$150 ded
20%
20% / $0
20% / $0
Flex Net Indemnity - Plan 9S1

5-2010
PPO
300 / 900

1500 / 4500

1 million

20% co-ins
20%
20%
$75 ded
20%
20% / $0
20% / $0
Health Net PPO, HMO, EPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
POS 10 - Plan 87C
5-2010
PPO
250 / 500

3000 single /
2 per family

5 million combined with PPO and OON
$20 copay
AD
$10
$25
0 $ded
10%

10% / $250 per calendar year

10% / $250 per calendar year
POS 10 - Plan 87C
5-2010
HMO
0 / 0

1500 / 3000

None
$10 copay
$10
$25
0 $ded
0%
0% / $0
0% / $0
POS 20 - Plan 87D
5-2010
PPO
500 / 1000

3500 single /
2 per family

5 million combined with PPO and OON
$30 copay
AD
$15
$30
0 $ded
20% AD

20% / $250 per calendar year

20% / $250 per calendar year
POS 20 - Plan 87D
5-2010
HMO
0 / 0

2000 / 4000

None
$20 copay
$15
$30
0 $ded
0%

0% / $250 per calendar year

0% / $250 per calendar year
Salud con Health Net PPO - Plan 9S2

5-2010
PPO
100 /
max 2 per family

2000 / 4000

5 million combined with PPO and OON
$15 copay
$10
$35
0 $ded
20% AD

20% / $250 per admission ded

20% / $250
Salud EPO Primero - Plan 9U2

5-2010
EPO
HMO
0 / 0

1500 / 4500

5 million
$15 copay
$10
$35
0 $ded
20%
0% / $250 per admit
20% / $0
Salud Mexico HMO - Plan 35W

5-2010
EPO
HMO
0 / 0

1500 / 4500

No Maximum
$5 copay
$5
$5
0 $ded
0%
0% / $0
0% / $0
Salud HMO y Mas 35 - Plan 9C8

5-2010
HMO
0 / 0

4000 / 8000

Unlimited Lifetime Max

$35 copay
$10
$35
$250 ded
20%

0% / $500 per day
(4 day copay max)

20% / $0
Salud HMO y Mas 25 - Plan 4Q7

5-2010
HMO
0 / 0

3500 / 7000

Unlimited Lifetime Max

$25 copay
$10
$35
$250 ded
20%

0% / $250 per day
(4 day copay max)

20% / $0
Salud HMO y Mas 15 - Plan 191

5-2010
HMO
0 / 0

1500 single /
3000 two-party /
4500 family

Unlimited Lifetime Max

$15 copay
$5
$15
$0 ded
20%

0% / $250 per day
(4 day copay max)

20% / $0
Salud con Health Net EPO - Plan 46C
11-09
EPO
HMO
0 / 0

1500 / 4500

5 million combined with PPO and OON
$15 copay
$10
$35
0 $ded
20%

0% / $250 per admission ded

20% / $0
Health Net HMO Plans

(EOA = Elect Open Access plan)
(SN = Silver Network plan)
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
EOA Standard 40 - Plan 873
SN EOA Standard 40 - Plan 7K1

5-2010
HMO
0 / 0

4000 / 8000

None
$40 copay
$15
$30
$0 ded
0%

0% / $1000 per day for max of 3 days per admit

0% / $1000
EOA Value 40 - Plan 877
SN EOA Value 40 - Plan 7K5

5-2010
HMO
0 / 0

4500 / 9000

None
$40 copay
$15
$30
250 $ded
40%
40% / $0
40% / $0
EOA Standard 30 - Plan 872
SN EOA Standard 30 - Plan 7J9

5-2010
HMO
0 / 0

3000 / 6000

None
$30 copay
$15
$30
$0 ded
0%

0% / $500 per day for a max of 3 days per admit

0% / $500
EOA Value 30 - Plan 876
SN EOA Value 30 - Plan 7K4

5-2010
HMO
0 / 0

3500 / 7000

None
$30 copay
$15
$30
200 $ded
30%
30% / $0
30% / $0
EOA Standard 20 - Plan 871
SN EOA Standard 20 - Plan 7J8

5-2010
HMO
0 / 0

2000 / 4000

None
$20 copay
$15
$30
$0 ded
0%

0% / $250 per day for a max of 3 days per admit

0% / $250
EOA Value 20 - Plan 875
SN EOA Value 20 - Plan 7K3

5-2010
HMO
0 / 0

2500 / 5000

None
$20 copay
$15
$30
150 $ded
20%
20% / $0
20% / $0
EOA Standard 10 - Plan 86Z
SN EOA Standard 10 - Plan 7J7

5-2010
HMO
0 / 0

1500 / 3000

None
$10 copay
$10
$25
$ded
0%
0% / $0
0% / $0
EOA Value 10 - Plan 874
SN EOA Value 10 - Plan 7k2

5-2010
HMO
0 / 0

2000 / 4000

None
$10 copay
$10
$25
100 $ded
10%
10% / $0
10% / $0
Health Net HMO Plans

(SN = Silver Network plan)
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
40 Standard HMO - Plan 885 and
SN 40 Standard HMO - Plan S44

5-2010
HMO
0 / 0

4000 / 8000

None
$40 copay
$15
$30
0 $ded
0%

0% / $1000 per day 3 day max

0% / $1000
40 Value HMO - Plan 88E and
SN 40 Value HMO - Plan S48

5-2010
HMO
0 / 0

4500 / 9000

None
$40 copay
$15
$30
$250 ded
40%
40% / $0
40% / $0
30 Standard HMO - Plan 884 and
SN 30 Standard HMO - Plan S42

5-2010
HMO
0 / 0

3000 / 6000

None
$30 copay
$15
$30
0 $ded
0%

0% / $500 per day, 3 day max

0% / $500
30 Value HMO - Plan 88D and
SN 30 Value HMO - Plan S45

5-2010
HMO
0 / 0

3500 / 7000

None
$30 copay
$15
$30
200 $ded
30%
30% / $0
30% / $0
20 Standard HMO - Plan 883 and
SN 20 Standard HMO - Plan S41

5-2010
HMO
0 / 0

2000 / 4000

None
$20 copay
$15
$30
0 $ded
0%

0% / $250 per day, max 3 days

0% / $250
20 Value HMO - Plan 88C and
SN 20 Value HMO - Plan S47

5-2010
HMO
0 / 0

2500 / 5000

None
$20 copay
$15
$30
150 $ded
20%
20% / $0
20% / $0
10 Standard HMO - Plan 888 and
SN 10 Standard HMO - Plan S43

5-2010
HMO
0 / 0

1500 / 3000

None
$10 copay
$10
$25
0 $ded
0%
0% / $0
0% / $0
10 Value HMO - Plan 88H and
SN 10 Value HMO - Plan S46
5-2010
HMO
0 / 0

2000 / 4000

None
$10 copay
$10
$25
100 $ded
10%
10% / $0
10% / $0
Health Net HMO Plans

(SN = Silver Network plan)
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Hn Options HMO 35 - Plan 87H
SN Hn Options HMO 35 - Plan S5Z

5-2010
HMO
0 / 0

4000 / 8000

No Lifetime Max

$35 copay
$15
$30
$200 ded
30%
30% / $0
30% / $0
Hn Options HMO 25 - Plan 87G
SN Hn Options HMO 25 - Plan S5Y


5-2010
HMO
0 / 0

3000 / 6000

No Lifetime Max

$25 copay
$15
$30
$150 ded
20%
20% / $0
20% / $0
Health Net HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible)
 Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)