| 2014 STANDARD BENEFITS FOR INDIVIDUALS |  Phone (310) 678-6315 |
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| KEY BENEFITS | Platinum | Gold | Silver (Lower Cost Sharing available on sliding scale) |
Bronze | |||
| Copays in the Yellow Sections are NOT subject to any Deductibles and count towards the annual out-of-pocket maximum |
Benefits in Blue Sections ARE subject to Deductibles | ||||||
| Deductible (if any) | No Deductible | No Deductible | $2,000 Medical Deductible | $5,000 Deductible for Medical & Drugs | |||
| Preventative Care Copay | No cost - at least 1 yearly visit | No cost - at least 1 yearly visit | |||||
| Primary Care Visit Copay | $20 | $30 | $45 | $60 - 3 visits per year | |||
| Specialty Care Visit Copay | $40 | $50 | $65 | $70 | |||
| Urgent Care Visit Copay | $40 | $90 | $60 | $120 | |||
| Lab Testing Copay | $20 | $30 | $45 | 30% | |||
| X-Ray Copay | $40 | $50 | $65 | 30% | |||
| Generic Medication Copay | $5 | $20 | $25 | $25 | |||
| Brand medications may be subject to Annual Drug Deductible before you pay the copay | No Deductible | No Deductible | $250 Deductible then pay the copay amount | $50-$75 after meeting deductible | |||
| Preferred brand copay after Drug Deductible (if any) | $15 | $50 | $50 | $50 | |||
| Emergency Room Copay | $150 | $250 | $250 | $300 | |||
| Imaging (MRI,CT,PET Scans) | $150 | $250 | $250 | 40% | |||
| High Cost & infrequent services like Hospital Care & Outpatient Surgery | HMO Outpatient Surgery - $250 Hospital - $250/day up to 5 days PPO - 10% |
HMO Outpatient Surgery - $600 Hospital - $600/day up to 5 days PPO - 20% |
$250 | 30% of your plan's negotiated rate | |||
| Maximum out-of-pocket for ONE | $4,000 | $6,350 | $6,350 | $6,350 | |||
| Maximum out-of-pocket for FAMILY | $8,000 | $12,700 | $12,700 | $12,700 | |||
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