TABLE II – GENERAL OVERVIEW OF BENEFITS

Covered Benefits

Plan A

Equal to or Less Than 150% FPL

Plan B

Over 150% FPL

Deductible

None

None

Provider Network

Enrollees choose between Public Employees Health Plan and Molina Health Care then choose from their network of providers.

The only exception is dental which is administered by PEHP and must be received through PEHP’s network of providers.  

Enrollees choose between Public Employees Health Plan and Molina Health Care then choose from their network of providers.

The only exception is dental which is administered by PEHP and must be received through PEHP’s network of providers.  

Quarterly premium

* See Note at end of table*

$13 per quarter 101-150% FPL

$25 per quarter 151-200%FPL

Out-of-pocket maximum

5% Annual Gross Countable Income

5% Annual Gross Countable Income

Lifetime Maximum

None

None

Pre-existing Conditions Waiting Period

No waiting period.

No waiting period.

InpatientHospital

$3 co-pay

Plan pays 90% of allowed charge. 

Inpatient Physician

$3 co-pay per visit

$15 co-pay per visit

Surgeon

Plan pays 100% of allowed charge.

Plan pays 100% of allowed charge.

OutpatientHospital

$3 co-pay

Plan pays 90% of allowed charge. 

Emergency Room

$3 co-pay per visit for emergencies.

 $35 co-pay per visit for emergencies.

Office Visit or Urgent CareCenter Visit

$3.00 co-pay per visit.

(No co-pay required for well child exams)

 $15 co-pay per visit.

(No co-pay required for well child exams)

Laboratory

$1 co-pay if less than $50

$2 co-pay if more than $50

$5 co-pay if less than $50

Plan pays 90% if more than $50

Laboratory

$1 co-pay if less than $50

$2 co-pay if more than $50

$5 co-pay if less than $50

Plan pays 90% if more than $50

X-ray

$1 co-pay if less than $100

$3 co-pay if more than $100

$5 co-pay if less than $100

Plan pays 90% if more than $100

Medical Equipment and Supplies

Plan pays 100 % of allowed amount.

Plan pays 80% .

Immunizations and Well Child Exams

No co-pay.  The plan pays 100% of the allowed amount.

No co-pay.  The plan pays 100% of the allowed amount.

Pharmacy

$1 per prescription for formulary drug.

$3 per prescription for non-formulary drug.

$5 per prescription for formulary drug.  50% of allowed amount for non-formulary drug.

Ambulance Ground and Air

Plan pays 100 % of allowed amount.

Plan pays 100 % of allowed amount.

Vision Screening Services

The plan pays $30 per child for eye exams.  Limit of one exam every 12 months.

The plan pays $30 per child for eye exams.  Limit of one exam every 12 months.

Dental Services:

-Cleaning, exams & fluoride;

-Selected X-Rays and sealants

-Selected fillings, space maintainers, pulpotomies, & stainless steel crowns.

The plan pays 100% for cleanings, exams, fluoride and selected x-rays and sealants.

$3 co-pay for selected maintainers, fillings, extractions, pulpotomies, and stainless steel crowns.

The plan pays 100% for cleanings, exams, fluoride and selected x-rays and sealants.

Plan pays 80% for selected maintainers, fillings, extractions, pulpotomies, and stainless steel crowns.

(Refer to PEDP benefit handbook, or contact PEDP for specific costs of services not covered at 100%)

Hearing Screening Services

The plan pays $30 per child for hearing screening.  Limit of one screening every 12 months.

The plan pays $30 per child for hearing screening.  Limit of one screening every 12 months.

Mental Health and Substance Abuse

(Combined totals)

Inpatient: $3 co-pay for each visit .

30 days per plan year, per child limit,

Outpatient: $3 co-pay for  each visit

30 visits per child, per plan year limit.

(Inpatient/Outpatient conversion available)

Inpatient  - Plan pays 90% for the first 10 days, 50% for the next 20 days.  30 days per child, per plan year limit.

Outpatient  - Plan pays 50% per visit

30 visits per child, per plan year limit.

(Inpatient/Outpatient conversion available)

Physical, Occupational, and Chiropractic Therapy

(Combined total)

$3 co-pay per visit. 

Limit of 16 visits total per plan year, per child.

$15 co-pay per visit. 

Limit of 16 visits total per plan year, per child.