TABLE II – Co-pay Summary

Benefits

(per plan year)

Co-pay Plan A*

(0 -  100% or below FPL)

Co-pay Plan B*

(101 - 150% FPL)

Co-pay Plan C*

(151 -200% FPL)

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.  

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.  

Out-of-pocket maximum

5% of family’s annual gross income

5% of family’s annual gross income

5% of family’s annual gross income

Premium

$0

$30/family/quarter

$60/family/quarter

Pre-existing Condition

No waiting period.

No waiting period.

No waiting period.

Deductible

None

None

$250/person; $500/family for inpatient, outpatient hospital and major diagnostic services

Well-Child Exams

$0

$0

$0

Immunizations

$0

$0

$0

Doctor Visits

$3

$5

$20

Specialist Visits

$3

$5

$25

Emergency Room

$3

$5

$75

Ambulance

$3

5% of total

20% of total

Urgent Care Center

$3

$5

$25

Ambulatory Surgical & Outpatient Hospital

$3

5% of total

10% after deductible

Inpatient Hospital Services**

$25

$100

10% after deductible

Lab & X-ray

$0 for x-ray/lab tests under $350; $3 for x-ray/lab tests over $350

$0 for x-ray/lab tests under $350; 5% of total for each test over $350

$0 for x-ray/lab test under $350;20% of total for each test over $350, after deductible

Surgeon

$0

$0

$0

Anesthesiologist

$0

$0

$0

Prescriptions

Preferred Generic Drugs

$1 for drug under $50; $3 for drug over $50

$5

$10

Preferred Brand Name Drugs

$1 for drug under $50; $3 for drug over $50

$5

25% of discounted cost up to a 30-day supply,  $5 minimum

Non-Preferred Drugs

5% of total

5% of total

50% of discounted cost up to a 30-day supply,  $5 minimum

Dental

Exams, Fluoride, etc.

$0

$0

$0

Selected Fillings, Crowns, etc.

$3

$5

20% of total

Mental Health**

Inpatient Hospital

$25 (20 day limit)

$100 (20 day limit)

30% after deductible   (20 day limit)

Outpatient Visit

$3

(20 visit limit)

5% of total

(20 visit limit)

30% of total

(20 visit limit)

Physical Therapy

$3 (20 visit limit)

$5 (20 visit limit)

$25 (20 visit limit)

Chiropractic Visits

$3 (8 visit limit)

$5 (8 visit limit)

$25 (8 visit limit)

Home Health & Hospice Care**

$3

5% of total

10% of total

Medical Equipment & Medical Supplies**

$3

5% of total

20% of total

Diabetes Education

$0

$0

$0

Vision Screening

$3 (limit 1)

$5 (limit 1)

$20 (limit 1)

Hearing Screening

$3 (limit 1)

$5 (limit 1)

$20 (limit 1)