Below is a brief summary of all medical plan options. For more details, review the benefit summaries found at the bottom of the page.
| Southern CA Select HMO | Open Acess Plus (OAP) | 1500 Copay Choice Fund w/HRA | 2000 Choice Fund w/HSA | 2500 Choice Fund w/HRA | |||||
|---|---|---|---|---|---|---|---|---|---|
| Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying. *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay. To be eligible for the HSA, you cannot be covered through Medicare Part A or Part B or TRICARE programs. See the plan documents for full details. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount. | |||||||||
| In-Network Only | In-Network Only | Out-of-Network1 | In-Network Only | Out-of-Network1 | In-Network Only | Out-of-Network1 | In-Network Only | Out-of-Network1 | |
| Deductible (per plan year) | |||||||||
| Individual / Family | None / None | $500 / $1,000 | $1,000 / $2,000 | $1,500 / $3,000 | $3,000 / $6,000 | $2,000 / $4,000 | $4,000 / $8,000 | $2,500 / $5,000 | $5,000 / $10,000 |
| Out-of-Pocket Maximum (per plan year) | |||||||||
| Individual / Family | $3,000 / $6,000 | $3,000 / $6,000 | $6,000 / $12,000 | $3,500 / $7,000 | $7,000 / $14,000 | $4,000 / $8,000 | $8,000 / $16,000 | $5,000 / $10,000 | $10,000 / $20,000 |
| Company Contribution to Your Health Savings Account (HSA) (per plan year; prorated for new hires/newly eligible) | |||||||||
| Individual / Family | N/A | N/A | $750 / $1,500 | $750 / $1,500 | $750 / $1,500 | ||||
| Covered Services | |||||||||
| Office Visits (physician/specialist) | $20 PCP / $40 Specialist | $20 PCP / $40 Specialist | 30%* | $25 PCP / $50 Specialist | 40%* | 20%* / 20%* | 40%* | 20%* | 40%* |
| Virtual Visits | $20 copay | $20 copay | Not covered | $25 copay | Not covered | 20%* | Not covered | 20%* | Not covered |
| Routine Preventive Care | No charge | No charge | 30%* through age 16, Not covered age 17+ | No charge | 40%* | No charge | 40%* | No charge | 40%* |
| Outpatient Diagnostic (lab/X-ray) | No charge / No charge | 10%* | 30%* | $25 copay | 20%* | 20%* | 40%* | 20%* | 40%* |
| Complex Imaging | No charge | 10%* | 30%* | $25 copay | 20%* | 20%* | 40%* | 20%* | 40%* |
| Chiropractic | $15 copay | $20 PCP / $40 Specialist | 30%* | $25 PCP / $50 Specialist | 40%* | 20%* | 40%* | 20%* | 40%* |
| Ambulance | No charge | 10%* | 20%* | 20%* | 20%* | 40%* | 20%* | 40%* | |
| Emergency Room | $150 copay | 100 copay, 100% after deductible | 20%* | 20%* | 20%* | 40%* | 20%* | 40%* | |
| Urgent Care Facility | $75 copay | 10%* | 30%* | 20%* | 40%* | 20%* | 40%* | 20%* | 40%* |
| Inpatient Hospital Stay | $250 copay | 10%* | 30%* | 20%* | 40%* | 20%* | 40%* | 20%* | 40%* |
| Outpatient Surgery | $125 copay | 10%* | 30%* | 20%* | 40%* | 20%* | 40%* | 20%* | 40%* |
| Prescription Drugs | (Generic / Brand / Non-Formulary) | ||||||||
| Retail Pharmacy (30-day supply) | $10 / $30 / $50 | $10 / $20 / $35 | Not covered | $10 / $30 / $50 | Not covered | $10 / $30 / $50 | Not covered | $10 / $30 / $50 | Not covered |
| Mail Order (90-day supply) | $25 / $75 / $125 | $30 / $60 / $105 | Not covered | $25 / $75 / $125 | Not covered | $25 / $75 / $125 | Not covered | $25 / $75 / $125 | Not covered |
Wellness Employee Contributions (effective 7.1.2022) Direct Link
| Employees earning less than $50,000/year | Employee Contributions Per Pay Period (26) |
|---|---|
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $72.22 |
| Employee + Spouse | $195.40 |
| Employee + Child(ren) | $182.34 |
| Employee + Family | $284.26 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $45.25 |
| Employee + Spouse | $160.41 |
| Employee + Child(ren) | $133.34 |
| Employee + Family | $206.14 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $60.58 |
| Employee + Spouse | $172.69 |
| Employee + Child(ren) | $159.12 |
| Employee + Family | $246.75 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $58.31 |
| Employee + Spouse | $179.64 |
| Employee + Child(ren) | $166.48 |
| Employee + Family | $269.17 |
| CIGNA OPEN ACCESS PLUS PPO | |
| Employee | $80.22 |
| Employee + Spouse | $220.19 |
| Employee + Child(ren) | $201.19 |
| Employee + Family | $350.59 |
| Employees earning between $50,000 - $99,999/year | Employee Contributions Per Pay Period (26) |
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $76.02 |
| Employee + Spouse | $205.68 |
| Employee + Child(ren) | $191.94 |
| Employee + Family | $299.22 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $47.64 |
| Employee + Spouse | $168.85 |
| Employee + Child(ren) | $140.36 |
| Employee + Family | $216.99 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $63.76 |
| Employee + Spouse | $181.79 |
| Employee + Child(ren) | $167.49 |
| Employee + Family | $259.74 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $61.38 |
| Employee + Spouse | $189.09 |
| Employee + Child(ren) | $175.24 |
| Employee + Family | $283.34 |
| CIGNA OPEN ACCESS PLUS PPO | |
| Employee | $84.02 |
| Employee + Spouse | $230.47 |
| Employee + Child(ren) | $210.78 |
| Employee + Family | $365.55 |
| Employees earning $100,000 or more/year | Employee Contributions Per Pay Period (26) |
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $83.63 |
| Employee + Spouse | $226.26 |
| Employee + Child(ren) | $211.13 |
| Employee + Family | $329.14 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $52.40 |
| Employee + Spouse | $185.74 |
| Employee + Child(ren) | $154.40 |
| Employee + Family | $238.68 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $70.14 |
| Employee + Spouse | $199.96 |
| Employee + Child(ren) | $184.24 |
| Employee + Family | $285.71 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $67.52 |
| Employee + Spouse | $208.00 |
| Employee + Child(ren) | $192.77 |
| Employee + Family | $311.68 |
| CIGNA OPEN ACCESS PLUS PPO | |
| Employee | $91.62 |
| Employee + Spouse | $251.04 |
| Employee + Child(ren) | $229.98 |
| Employee + Family | $395.47 |
Non-Wellness Employee Contributions (effective 7.1.2022) Direct Link
| Employees earning less than $50,000/year | Employee Contributions Per Pay Period (26) |
|---|---|
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $97.22 |
| Employee + Spouse | $220.40 |
| Employee + Child(ren) | $207.34 |
| Employee + Family | $309.26 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $70.26 |
| Employee + Spouse | $185.41 |
| Employee + Child(ren) | $158.34 |
| Employee + Family | $231.14 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $85.58 |
| Employee + Spouse | $197.70 |
| Employee + Child(ren) | $184.12 |
| Employee + Family | $271.75 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $83.31 |
| Employee + Spouse | $204.64 |
| Employee + Child(ren) | $191.48 |
| Employee + Family | $294.17 |
| CIGNA OPEN ACCESS PLUS | |
| Employee | $105.22 |
| Employee + Spouse | $245.19 |
| Employee + Child(ren) | $226.19 |
| Employee + Family | $375.59 |
| Employees earning between $50,000 - $99,999/year | Employee Contributions Per Pay Period (26) |
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $101.03 |
| Employee + Spouse | $230.69 |
| Employee + Child(ren) | $216.94 |
| Employee + Family | $324.22 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $72.64 |
| Employee + Spouse | $193.86 |
| Employee + Child(ren) | $165.36 |
| Employee + Family | $241.99 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $88.76 |
| Employee + Spouse | $206.79 |
| Employee + Child(ren) | $192.49 |
| Employee + Family | $284.74 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $86.39 |
| Employee + Spouse | $214.09 |
| Employee + Child(ren) | $200.24 |
| Employee + Family | $308.34 |
| CIGNA OPEN ACCESS PLUS PPO | |
| Employee | $109.02 |
| Employee + Spouse | $255.47 |
| Employee + Child(ren) | $235.79 |
| Employee + Family | $390.55 |
| Employees earning $100,000 or more/year | Employee Contributions Per Pay Period (26) |
| CIGNA 1500 CHOICE FUND WITH HRA | |
| Employee | $108.63 |
| Employee + Spouse | $251.26 |
| Employee + Child(ren) | $236.13 |
| Employee + Family | $354.14 |
| CIGNA 2500 CHOICE FUND WITH HRA | |
| Employee | $77.40 |
| Employee + Spouse | $210.74 |
| Employee + Child(ren) | $179.40 |
| Employee + Family | $263.69 |
| CIGNA 2000 CHOICE FUND WITH HSA | |
| Employee | $95.14 |
| Employee + Spouse | $224.96 |
| Employee + Child(ren) | $209.24 |
| Employee + Family | $310.71 |
| CIGNA SOUTHERN CA SELECT HMO | |
| Employee | $92.52 |
| Employee + Spouse | $233.00 |
| Employee + Child(ren) | $217.77 |
| Employee + Family | $336.68 |
| CIGNA OPEN ACCESS PLUS PPO | |
| Employee | $116.62 |
| Employee + Spouse | $276.04 |
| Employee + Child(ren) | $254.98 |
| Employee + Family | $420.47 |