2026-2027 Plan Comparison - Old Adobe (1).xlsx

	A	B	C	D	E	F	G	H	I	J	K	L
1		HMO	HMO	HMO	HMO	HMO	PPO	PPO	PPO	PPO	PPO	PPO
2		Kaiser	Kaiser	Kaiser	Kaiser	Kaiser	Blue Shield	Blue Shield	Blue Shield	Blue Shield	Blue Shield	ProactiveCare
3
4
5	Old Adobe	Kaiser	Kaiser	Kaiser	Kaiser	Kaiser	Blue Shield	Blue Shield	Blue Shield	Blue Shield	Blue Shield	ProactiveCare
6	2026-2027	$10 OV, $10 Rx	$20 OV, $10-20 Rx (Non-Marketed)	DHMO $500	HSA $1,700 SNG	HSA $1,700 FAM	100-B $20	90-E $20 (Non-Marketed)	80-G $30 (Non-Marketed)	HSA $3,400	2-Tier HSA $5,000	Diamond
7
8	MEDICAL - CALENDAR YEAR Deductibles & Maximums	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays
9	Individual/Family Deductibles (Ded)	$0	$0	$500/ $1,000	$1,700*	$3,200/ $3,200*	$100/$300	$300/$600	$500/$1,000	$3,400/$6,800*	$5,000/$10,000*	$0/$0
10	Individual/Family Out-of-Pocket (OOP) Max (includes medical deductibles, co-insurance and co-pays)	$1,500/$3,000	$1,500/$3,000	$3,000/$6,000	$3,400*	$3,400/$6,800*	$1,000/$3,000	$1,000/$3,000	$2,000/$4,000	$6,000/$12,000*	$6,350/$12,700*	$1,000/$3,000
11					*Includes Rx	*Includes Rx				*Includes Rx	*Includes Rx
12	PROFESSIONAL SERVICES
13	Primary Care* visit co-pay ($0 Copay for 1st 3 cal yr Primary Care OV on Non-HSA PPO plans)	$10	$20	$20	Deductible, then 10% after Ded	Deductible, then 10% after Ded	$20	$20	$30	Deductible, then 10% after Ded	Deductible, then 30% after Ded	$0
14	Urgent Care co-pay	$10	$20	$20	10% after Ded	10% after Ded	$20	$20	$30	10% after Ded	30% after Ded	$0
15	Prenatal, postnatal office visit co-pay	$0	$0	$0	$0	$0	$20	$20	$30	10% after Ded	30% after Ded	$0
16	Specialists/Consultants co-pay	$10	$20	$20	10% after Ded	10% after Ded	$20	$20	$30	10% after Ded	30% after Ded	$40
17												Non-Hosp/OPH**
18	Scans: CT, CAT, MRI, PET etc.	$0	$0	10% after Ded Copay up to $50	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$100/$250
19	Laboratory Procedures	$0	$0	$10	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0/$50
20	Diagnostic X-rays	$0	$0	$10	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$25/$75
21	Infertility (Refer to Plan Document)	Co-pay applies	Co-pay applies	Co-pay applies	Co-pay applies	Co-pay applies	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
22	Preventive Care (includes physical exams & screenings)	$0	$0	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	$0
23
24	HOSPITAL & SKILLED NURSING FACILITY SERVICES
25	Emergency Room visit (copay waived if admitted) - Avg Cost: $2,847 \| $100+10%: $375 \| $100+20%: $649	$100	$100	10% after Ded	10% after Ded	10% after Ded	0% after Ded $100 co-pay	10% after Ded $100 co-pay	20% after Ded $100 co-pay	10% after Ded $100 co-pay	30% after Ded $100 co-pay	$300
26	Inpatient Hospital (preauthorization required) - Avg Cost for one day: $6,067 \| 10%: $607 \| 20%: $1,213	$0	$0	10% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$200/day
27	Surgery, Outpatient (performed in Surgery Center)	$10	$20	10% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$200
28	Surgery, Outpatient (performed in a Hospital) - limits may apply	$10	$20	10% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$600
29
30	MENTAL HEALTH & SUBSTANCE ABUSE TREATMENT
31	INPATIENT: Facility Based Care (preauth required)	$0	$0	10% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$200/day
32	OUTPATIENT: Facility Based Care (preauth required)	$10	$20	10% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0
33
34	OTHER SERVICES
35	Ambulance (Ground or Air)	$50	$50	$150	10% after Ded	10% after Ded	0% after Ded $100 co-pay	10% after Ded $100 co-pay	20% after Ded $100 co-pay	10% after Ded $100 co-pay	30% after Ded $100 co-pay	$300
36	Acupuncture - Limits apply	$10/30 visits (through ASH) combined w/chiro	$10/30 visits (through ASH) combined w/chiro	$10/30 visits (through ASH) combined w/chiro	Requires Prior Authorization	Requires Prior Authorization	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0
37	Chiropractic - Limits apply	$10/30 visits (through ASH) combined w/acu	$10/30 visits (through ASH) combined w/acu	$10/30 visits (through ASH) combined w/acu	no coverage	no coverage	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0
38	Physical and Occupational Therapy - Limits apply	$10	$20	$20	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0
39	Durable Medical Equipment (DME)	no charge	no charge	20% after Ded	10% after Ded	10% after Ded	0% after Ded	10% after Ded	20% after Ded	10% after Ded	30% after Ded	$0
40	Hearing Aids	amount in excess of $500 allowance every 36 months	amount in excess of $500 allowance every 36 months	amount in excess of $500 allowance every 36 months	no coverage	no coverage	Amount in excess of $700 allowance/24 months	10% after Ded and Amount in excess of $700 allowance/24 months	20% after Ded and Amount in excess of $700 allowance/24 months	10% after Ded and Amount in excess of $700 allowance/24 months	30% after Ded and Amount in excess of $700 allowance/24 months	$0 plus the amount in excess of $700 allowance/24 months
41	*Primary Care Providers (PCPs) are those without specialty certifications, practicing general pediatrics, internal medicine, family or general practice, or obstetrics and gynecology.
42
43
44	PHARMACY BENEFITS
45	Plan	$10 Rx	$10-20 Rx (Non-Marketed)	$10-30 (30 day) Rx	HSA $1,700 Rx	HSA $1,700 Rx	Rx 7-25	Rx 7-25	Rx 9-35	Rx HSA	Rx HSA	Rx 9-35 PC
46	Pharmacy Benefit Manager	Kaiser	Kaiser	Kaiser	Kaiser	Kaiser	Navitus	Navitus	Navitus	Navitus	Navitus	Navitus
47	Individual/Family Brand & Specialty Rx Deductibles	none	none	none	Included w/ Medical ded	Included w/ Medical ded	none	none	none	Included w/ Medical ded	Included w/ Medical ded	none
48	Individual/Family Rx Out-of-Pocket (OOP) Max (includes Rx deductibles and co-pays)	Included w/ Med OOP Max	Included w/ Med OOP Max	Included w/ Med OOP Max	Included w/ Med OOP Max	Included w/ Med OOP Max	$1,500/$2,500	$1,500/$2,500	$2,500/$3,500	Included w/ Med OOP Max	Included w/ Med OOP Max	$2,500/$3,500
49	Generic co-pay/30 days supply	$10 up to 100 day supply	$10 up to 100 day supply	$10 up to 30 day supply	deductible, then $10	deductible, then $10	$0 at Costco‡ $7 at Other Network	$0 at Costco‡ $7 at Other Network	$0 at Costco‡ $9 at Other Network	Deductible, then $0 at Costco or $9 at Other Network	Deductible, then $0 at Costco or $9 at Other Network	$0 at Costco‡ $9 at Other Network
50	Brand co-pay/30 days supply	$10 up to 100 day supply	$20 up to 100 day supply	$30 up to 30 day supply	deductible, then $30	deductible, then $30	$25	$25	$35	Deductible, then $35	Deductible, then $35	$35
51	Specialty co-pay/up to 30 days supply	$10 up to 30 day supply	$20 up to 30 day supply	$30 up to 30 day supply	deductible, then $30	deductible, then $30	$25 Must Use Navitus Mail	$25 Must Use Navitus Mail	$35 Must Use Navitus Mail	Deductible, then $35 (Must Use Navitus Mail)	Deductible, then $35 (Must Use Navitus Mail)	$35 Must Use Navitus Mail
52	Mail Order (Generic-Brand co-pay/90 days supply)	$10-$10/up to 100 day supply	$10-$20/up to 100 day supply	$20-$60 up to 100 day supply	$20-$60/up to 100 day supply	$20-$60/up to 100 day supply	$0-$60‡	$0-$60‡	$0-$90‡	Deductible, then $0-$90	Deductible, then $0-$90	$0-$90‡
53	Mail Order Pharmacy	Kaiser Mail Order Pharmacy	Kaiser Mail Order Pharmacy	Kaiser Mail Order Pharmacy	Kaiser Mail Order Pharmacy	Kaiser Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy
54
55	Payroll Deductions, Employee Contributions, etc.
56
57
58
59	This comparison displays member cost-share for In-Network services. Out-of-Network services may not be covered. Please refer to the plan documents available through your district for applicable details, limitations, and exclusions. Employee cost/payroll deduction, if applicable, can be requested from the district.
60
61	‡Some narcotic pain and cough medications are not included in the Costco Free Generic or 90-day supply programs.
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100