Cabrillo College
2014.10.01 Plan
Designs
2014.10.01 Plan Designs
2014/15 Renewal
Benefits
Calendar Year Deductible
Out-of-Pocket Maximum
Individual / Family
MAJOR MEDICAL
HMO $30-20%
Zero Facility w/Chiro
HMO $25-500 w/Chiro
HMO $10-0 w/Chiro
PPO 80-E
PPO 80-J
PPO HDHP -B w/HSA Compatibility
None
$1,500 per member
Calendar Year Copayment Maximum
None
$2,000 / $4,000
Calendar Year Copayment Maximum
None
$1,000 / $2,000
Calendar Year Copayment Maximum
$300 p/ind; $600 p/fam
$1,000 p/ind; $3,000 per fam
Calendar Year Out-of-Pocket Max
$750 p/ind; $1,500 p/fam
$3,000 p/ind; $6,000 per fam
Calendar Year Out-of-Pocket Max
$2,500 p/ind; $5,000 p/fam
$5,000 p/ind or $10,000 per fam
Calendar Year Out-of-Pocket Max
In Network
Out of Network
In Network
Out of Network
In Network
$30
$25
$10
Ded waived; $20
50%
Ded waived; $30
50%
90%
50%
$30/$45
$25/$30
$10/$30
Ded waived; $20
50%
Ded waived; $30
50%
90%
50%
Physician Office Visit
Specialist Visit
Out of Network
Preventive Care
$0
$0
No charge
Ded waived; 100%
Not Covered
Ded waived; 100%
Not Covered
Ded waived; 100%
Not Covered
Inpatient Hospital
20% up to $1,500 p/member
$500 / Admit
No charge
80%
$600 p/day
80%
$600 p/day
90%
$600 p/day
Lab & X-Ray
No charge
No charge
80%
50%
80%
50%
90%
50%
Outpatient Surgery
No charge
No charge
80%
$350 p/day
80%
$350 p/day
90%
$350 p/day
$100 (waived if admitted)
$150 (waived if admitted)
No charge
$150 at an Ambulatory Surgery Center;
$300 at a Hospital
$100 (waived if admitted)
Mental Health Care/Substance Abuse
20% up to $1,500 p/member
$500 / Admit
No charge
Ded waived; $20
50%
Ded waived; $30
50%
90%
Inpatient Hospital Facility
20% up to $1,500 p/member
$500 / Admit
No charge
80%
50%
80%
50%
90%
50%
Outpatient Physician Visit
$30 per visit
$25 per visit
$10
Ded waived; $20
50%
Ded waived; $30
50%
90%
50%
Navitus / Costco (Mail Order)
Navitus / Costco (Mail Order)
Navitus / Costco (Mail Order)
Navitus / Costco (Mail Order)
Navitus / Costco (Mail Order)
Generic/Brand
Generic/Brand
Generic/Brand
Generic/Brand
Generic/Brand
Retail - 30 day supply
$9/$35
$9/$35
$5/$10
$7
$25
$9
$35
Mail order - 90 day supply
$18/$90
$18/$90
$10/$20
$14
$60
$18
$90
N/A
N/A
N/A
Emergency Room
Outpatient Prescription Drugs
(At participating Pharmacies only)
Annual Deductible
Actives
$100 copay
$100 copay
$100 copay
$300 p/ind; $600 p/fam
50%
Rx w/ Blue Shield Contracted Provider
Generic/Brand
$7
$25
$14
$60
$2,500 medical deductible must be met
before co-pays apply
$750 p/ind; $1,500 p/fam
2013 - 2014
2014 - 2015
31
$670
$724
97
2013 - 2014
$721
2014 - 2015
$771
14
2013 - 2014
$910
2014 - 2015
$975
28
2013 - 2014
$910
2014 - 2015
$956
15
2013 - 2014
$807
2014 - 2015
$848
25
2013 - 2014
$643
2014 - 2015
$681
Employee + 1
7
$1,309
$1,417
49
$1,412
$1,512
15
$1,766
$1,890
17
$1,690
$1,778
12
$1,500
$1,578
2
$1,209
$1,281
Family
26
$1,995
87
$1,985
$2,130
15
$2,470
$2,641
9
$2,515
$2,645
11
$2,231
$2,348
3
$1,835
$1,943
Total Monthly Premium
64
$1,838
$77,721
$84,233
233
$311,820
$334,185
44
$76,280
$81,615
54
$76,845
$80,799
38
$54,646
$57,484
30
$23,998
$25,416
$932,652
$1,010,796
$3,741,840
$4,010,220
$915,360
$979,380
$922,140
$969,588
$655,752
$689,808
$287,976
$304,992
Employee Only
Total Annual Premium
$ ∆ to Current
$78,144
$268,380
$64,020
$47,448
$34,056
$17,016
% ∆ to Current
8.4%
7.2%
7.0%
5.1%
5.2%
5.9%