| Plan Details | ||
|---|---|---|
| Plan Name | HMO SCAL | |
| Effective Dates | Jan 01, 2025 to Jan 01, 2026 | |
| Benefits | In-Network | |
| Annual Deductible/Individual | $0 | |
| Annual Deductible/Family | $0 | |
| Coinsurance | 0% | |
| Office Visit/Exam | $30 | |
| Outpatient Specialist Visit | $30 | |
| Annual Out-of-Pocket Limit/Individual | $3,000 | |
| Annual Out-of-Pocket Limit/Family | $6,000 | |
| Preventive Care | 0% | |
| Inpatient Hospitalization | $500 /day | |
| Surgical Services Outpatient Facility Charge | $250 /procedure | |
| Emergency Room | $100 | |
| Urgent Care Facility | $30 | |
| Prescription Drug Deductible | $0 | |
| Prescription Drugs - Generic | $10 | |
| Prescription Drugs - Brand (Formulary/Preferred) | $30 | |
| Prescription Drugs - Brand (Non-Formulary/Non-preferred) | $30 | |
| Prescription Drugs - Specialty | 20% up to $150 | |
| Chiropractic Services | Not Covered | |
| Acupuncture | Covered | |