Plan Details
Plan Name	Deductible HMO (Southern CA)
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network
Annual Deductible/Individual	$750
Annual Deductible/Family	$1,500
Coinsurance	20%
Office Visit/Exam	$25 deductible does not apply
Outpatient Specialist Visit	$25 deductible does not apply
Annual Out-of-Pocket Limit/Individual	$3,000
Annual Out-of-Pocket Limit/Family	$6,000
Preventive Care	0% deductible does not apply
Inpatient Hospitalization	20%
Surgical Services Outpatient Facility Charge	20%
Emergency Room	20%
Urgent Care Facility	$25 deductible does not apply
Prescription Drug Deductible	$0
Prescription Drugs - Generic	$10 drug deductible does not apply
Prescription Drugs - Brand (Formulary/Preferred)	$30 drug deductible does not apply
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$30 drug deductible does not apply
Prescription Drugs - Specialty	20% up to $200 drug deductible does not apply
Chiropractic Services	$25 deductible does not apply; 30 visit limit / year combined with acupuncture
Acupuncture	$25 deductible does not apply; 30 visit limit / year combined with chiropractic