Annual Deductible (calendar year) |
None |
N/A |
None |
N/A |
None |
N/A |
$2,000 Individual/ $3,300 Per Member/ $4,000 Family |
$5,000 Individual/ $5,000 Per Member/ $10,000 Family |
Coinsurance |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
80% |
80% |
Annual Out-of-Pocket Maximum (calendar year) |
$2,500 Individual $5,000 Family |
N/A |
$4,000 Individual $8,000 Family |
N/A |
$4,000 Individual $8,000 Family |
N/A |
$3,300 Individual/ $3,300 Per Member/ $6,500 Family |
$9,000 Individual/ $9,000 Per Member/ $18,000 Family |
SCAN Contribution to Health Savings Account (HSA) |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
CA Employees $600/year for Individual Coverage $1,200/year for Family Coverage
Non-CA Employees $1,250/year for Individual coverage $2,250/year for Family coverage
|
Physician Services: Your Costs |
Preventive care |
Covered 100% |
N/A |
Covered 100% |
N/A |
Covered 100% |
N/A |
Covered 100%* |
You pay 40% after deductible |
Primary Care Office Visit |
$20 copay |
N/A |
$40 copay |
N/A |
$20 copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Specialist Office Visit |
$40 copay |
N/A |
$60 copay |
N/A |
$30 copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Lab/X-ray |
No copay |
N/A |
$30 copay |
N/A |
$30 copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Imaging (CT/MRIs) |
$100 copay per type of scan |
N/A |
$250 copay per type of scan |
$100 copay per type of scan |
20% coinsurance per scan |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Physical Therapy – up to 20 visits (calendar year) |
$40 copay |
N/A |
$60 copay |
N/A |
$30 copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Durable medical equipment |
$20 copay |
N/A |
$40 copay |
N/A |
$20 copay |
N/A |
50% |
50% |
Hospital Services: Your Costs |
Inpatient** |
$500 copay per admission |
N/A |
$500 per day, up to three days |
N/A |
20% per admission |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Outpatient |
$200 copay per visit |
N/A |
$125 copay per visit |
N/A |
20% per visit |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Emergency Room |
$150 copay (waived if admitted) |
N/A |
$250 copay (waived if admitted) |
N/A |
20% |
N/A |
You pay 20% after deductible |
You pay 20% after deductible |
Ambulance |
$150 copay |
N/A |
$250 copay |
N/A |
20% |
N/A |
You pay 20% after deductible |
You pay 20% after deductible |
Urgent Care |
$50 copay |
N/A |
$75 copay |
N/A |
No copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Mental Health Care: Your Costs |
Inpatient |
$500 copay |
N/A |
$500 per day, up to three days |
N/A |
20% copay per admission |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Outpatient |
$40 copay |
N/A |
$60 copay |
N/A |
$30 copay |
N/A |
You pay 20% after deductible |
You pay 40% after deductible |
Prescription drugs: Your costs |
Deductible |
N/A |
N/A |
$200 per individual / $400 per family |
N/A |
N/A |
N/A |
Annual deductible applies |
N/A |
Retail Pharmacy (30-day supply) |
Tier 1 |
$10 |
N/A |
$10 |
N/A |
$10 |
N/A |
$10 |
40% up to $250 |
Tier 2 |
$30 |
N/A |
$30 |
N/A |
$30 |
N/A |
$30 |
40% up to $250 |
Tier 3 |
$50 |
N/A |
$55 |
N/A |
$50 |
N/A |
$50 |
40% up to $250 |
Tier 4 |
30% up to $250 per fill |
N/A |
30% up to $250 per fill |
N/A |
30% up to $250 per fill |
N/A |
30% up to $250 per fill |
Not covered |
Mail Order (90-day supply) |
Tier 1 |
$20 |
N/A |
$20 |
N/A |
$20 |
N/A |
$25 |
Not covered |
Tier 2 |
$60 |
N/A |
$60 |
N/A |
$60 |
N/A |
$90 |
Not covered |
Tier 3 |
$100 |
N/A |
$110 |
N/A |
$100 |
N/A |
$100 |
Not covered |
Tier 4 |
30% up to $250 per fill |
N/A |
30% up to $250 per fill |
N/A |
30% up to $250 per fill |
N/A |
Not covered |
Not covered |