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Plan Comparison - Office MMC in CA
Compare your benefit choices
Plan details Trio HMO Access+ HMO EPO* PPO HDHP PPO
In-network In-network In-network In-network Non-network In-network Non-network
Calendar-year deductible $500 Individual/ $1,500 Famiy $500 Individual/ $1,000 Famiy $500 Individual/ $1,000 Famiy $5,000 Individual/ $10,000 Family $5,000 Individual/ $10,000 Family
Medical out-of-pocket maximum $1000 Individual/ $3000 Family $1000 Individual/ $3000 Family $3,500 Individual/ $7,000 Family $2,500 Individual/ $5,000 Family $3,500 Individual/ $7,000 Family $6,000 Individual/ $12,000 Family $6,000 Individual/ $12,000 Family
Hopital and Physician services
Primary care physician $25/visit $25/visit $25/visit $25/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Specialist care office visit (referred by PCP on HMO) $25/visit $25/visit $35/visit $35/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Preventive health exam $0/visit $0/visit $0 $0 50% Deductible applies $0 Not covered
Outpatient x-ray, pathalogy and laboratory (non-hospital facilities) $25/visit $25/visit $25/visit $0 $0 20% Deductible applies 50% Deductible applies
Outpatient surgery in hospital $0 $0 $250/surgery Deductible applies $0 Deductible applies 50% Subject to a Benefit maximum of $2,000/day
Deductible applies		 20% Deductible applies 50% Subject to a Benefit maximum of $350/day
Deductible applies

Inpatient facility services
$500/admission
$500/admission
$500/admission plus 20%

Deductible applies
$500/admission plus 20%
Deductible applies		 $500/admission plus 50%
Subject to a Benefit maximum of $2,000/day
Deductible applies
$100/admission plus 20% Deductible applies
 50% Subject to a Benefit maximum of $600/day
Deductible applies
Virtual services
Teladoc (virtual medical doctor visits) $0 $0 $0 $0 Not covered $0 Deductible applies Not covered
Teladoc (mental health professional video or phone consultation) $0 $0 $0 $0 Not covered $0 Deductible applies Not covered
Emergency care
Urgent care center $25/visit $25/visit $25/visit $25/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Emergency room services facilities $125/visit $125/visit $125/visit plus 20% $125/visit plus 20% $125/visit plus 20% $150/visit plus 20% Deductible applies $150/visit plus 20% Deductible applies
Ambulance services $0 $0 20% Deductible applies 20% Deductible applies 20% Deductible applies 20% Deductible applies 20% Deductible applies
Specialty services
Pregnancy and maternity care (Prenatal and Postnatal) $25/visit $25/visit $25/visit $25/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Acupuncture services $15/visit $15/visit $25/visit $25/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Chiropractic services $15/visit $15/visit $25/visit $25/visit 50% Deductible applies 20% Deductible applies 50% Deductible applies
Mental health office visit $0 $0 $0 $0 50% Deductible applies 20% Deductible applies 50% Deductible applies
Mental health inpatient services facilities $500/admission $500/admission $500/admission plus 20% Deductible applies $500/admission plus 20% Deductible applies 50% Deductible applies $100/admission plus 20% Deductible applies 50% Deductible applies
Substance abuse (inpatient/outpatient facilities) $500/admission inpatient /
$0 outpatient		 $500/admission inpatient /
$0 outpatient		 $500/admission plus 20% Deductible applies Inpatient/
$0 Outpatient		 $500/admission plus 20% Deductible applies Inpatient/
$0 Outpatient		 50% Deductible applies $100/admission plus 20% Deductible applies Inpatient/
20% Deductible applies Outpatient		 50% Deductible applies
Pharmacy benefits
Retail prescription (30-day supply)
Contraceptive drugs and devices $0/prescription $0/prescription $0/prescription $0/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment $0/prescription Applicable Tier 1, Tier 2, or Tier 3 Copayment
Value Based Tier drugs or HDHP preventative drugs $0/prescription $0/prescription $0/prescription $0/prescription Not covered $0/prescription Not covered
Tier 1 Drugs $10/prescription $10/prescription $10/prescription $10/prescription 25% plus $10/prescription Deductible applies $10/prescription Deductible applies 25% plus $10/prescription Deductible applies
Tier 2 Drugs $25/prescription $25/prescription $25/prescription $25/prescription 25% plus $25/prescription Deductible applies $25/prescription Deductible applies 25% plus $25/prescription Deductible applies
Tier 3 Drugs $40/prescription $40/prescription $40/prescription $40/prescription 25% plus $40/prescription Deductible applies $40/prescription Deductible applies 25% plus $40/prescription Deductible applies
Tier 4 Drugs $40/prescription $40/prescription $40/prescription $40/prescription 25% plus $40/prescription Deductible applies $40/prescription Deductible applies 25% plus $40/prescription Deductible applies
Mail-service prescriptions (up to 90-day supply)
Contraceptive drugs and devices $0/prescription $0/prescription $0/prescription $0/prescription Not covered $0/prescription Not covered
Value Based Tier Drugs or HDHP preventative drugs $0/prescription $0/prescription $0/prescription $0/prescription Not covered $0/prescription Not covered
Tier 1 drugs $20/prescription $20/prescription $20/prescription $20/prescription Not covered $20/prescription Deductible applies Not covered
Tier 2 drugs $50/prescription $50/prescription $50/prescription $50/prescription Not covered $50/prescription Deductible applies Not covered
Tier 3 drugs $80/prescription $80/prescription $80/prescription $80/prescription Not covered $80/prescription Deductible applies Not covered
Tier 4 drugs $80/prescription $80/prescription $80/prescription $80/prescription Not covered $80/prescription Deductible applies Not covered

*Out-of-network services are not covered under the EPO plan.