Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED AETNA PLANS
DISCONTINUED
Aetna PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
MC HRA HDHP $5000 80/50

4-08
PPO
5000 indiv /
10000 fam
2000 indiv /
4000 family
$0 copay /
20% co-insurance
$20
$40
AD $ded
20%
20% / $0
20% / $0
EPO Limited (Open Access)

4-08
PPO
1000 indiv
4500 indiv
$0 copay /
50% co-insurance
$20
$40
AD $ded
50%
50% / $0
50% / $0
MC 2500 100/50

12-07
PPO
2500 indiv /
7500 fam
0 / 0
$25 copay /
0% co-insurance
$15
$35
0 $ded
0%
0% / $0
0% / $0
MC $500 50/50

12-07
PPO
500 indiv /
2 mem max
5000 indiv /
2 member max
$35 copay /
0% co-insurance
$15
na
0 $ded
50%
50% / $0
50% / $150
DISCONTINUED
Aetna HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
HMO $30/$40

4-07
HMO
0 / 0
3000 indiv /
6000 family
$30 copay / na
$15
$35
0 $ded
0%
0% / $500
0% / $250
HMO $20/$40

4-07
HMO
0 / 0
2500 indiv /
5000 family
$20 copay / na
$15
$35
0 $ded
0%
0% / $500
0% / $250
HMO $10/$30

4-07
HMO
0 / 0
2000 indiv /
4000 family
$10 copay / na
$15
$35
0 $ded
0%
0% / $300
0% / $250
HMO $10/$20

4-07
HMO
0 / 0
1500 indiv /
3000 family
$10 copay / na
$10
$25
0 $ded
0%
0% / $0
0% / $0
Value Network* HMO $30/$40

4-07
HMO
0 / 0
3000 indiv /
6000 family
$30 copay / na
$15
$35
150 $ded
0%
0% / $1000
0% / $250
Value Network* HMO $10/$20

4-07
HMO
0 / 0
1500 indiv /
3000 family
$10 copay / na
$10
$25
0 $ded
0%
0% / $0
0% / $0
DISCONTINUED
Aetna HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)

In-Network
Out/pocket max

Lifetime Max

In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED ANTHEM BLUE CROSS PLANS
DISCONTINUED
Anthem Blue Cross PPO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Hospital BeneFits Preferred
Overview of changes

2-2011
7-09
PPO
750 / 1500

3250 / 6500

50% co-ins

$15
na
no ded
30%
30% / $0
30% / $0
AD
Hospital BeneFits Plus

2-2011
PPO
1000 / 2000

3500 / 7000

50% co-ins
$15
na
0 $ded
30%
30% / $0
50% / $0
AD
Hospital BeneFits

2-2011
PPO
1250 / 2500

3750 / 7500

100% co-ins
$15
na
0 $ded
30%
30% / $0
50% / $0
AD
Lumenos HSA 5000 (100/70)

10-2010
PPO
5000 / 10000
aggregate
5800 / 11600
aggregate
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 3000

10-2010
PPO
3000 / 6000
aggregate
5000 / 10000
aggregate
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 2000

10-2010
PPO
2000 / 4000
aggregate
4000 / 8000
aggregate
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos HSA 1500 (100/70)

7-09
PPO
1500 / 3000
aggregate
3000 / 6000
aggregate
0% co-ins
AD
$10
$30
AD
0%
0% / $0
0% / $0
AD
Lumenos® HIA Plus 3000 discontinued

7-09
PPO
3000 / 6000 aggregate

Health Incentive Plan Allocation
1000 / 2000 aggregate

3000 / 6000 aggregate

0% co-ins
AD

0%
0%
AD
0%
0% / $0
0% / $0
AD
PPO 3500 HSA-Compatible

7-09
PPO
3500 / 7000
aggregate

4000 / 7500
aggregate

$35 copay
AD
$10
$25
AD
0%
0% / $0
0% / $0
AD
Saver PPO Plan

7-09
PPO
5500 / 11000
7000 / 14000
2 visits /
$20 copay
$10
$25
AD
20%
20% / $0
20% / $0
After $500 ded
Basic PPO Plan

7-09
PPO
1250 / 2500
3250 / 6500
not covered

$10
$25
AD

20%
20% / $0
20% / $0
AD
Advantage $25 Copay*

7-09
PPO
250 / 500
3600 / 7200
12 visits / $25 copay /
45% co-ins up to $900 and then 10% co-insurance from $901 to $3,600
$15
$25
AD
30% up to $900, 10% from $901 to $3600

30% up to $900, 10% from $901 to $3600 / $0

30% up to $900, 10% from $901 to $3600 / $0

Power Healthfund 750*

7-09
PPO

500 / 1000

First Dollar Coverage
750 / 1500

5000 / 10000

$35 copay
$10
$30
$250 ded
25%
25% / $0
25% / $0
AD
(when First Dollar Coverage is used up)
Power Healthfund 500*

7-09
PPO

1000 / 2000
aggregate

First Dollar Coverage
$500 / $1000

5000 / 10000
aggregate

$40 copay
$10
$35
$350 ded
40%
40% / $0
40% / $0
AD
(When First Dollar Coverage is used up)
PPO 2400 HSA-Compatible

2-08
PPO
2400 / 4800
aggregate

3600 / 5500
aggregate

$35 copay
AD
$10
$25
AD
20%
20% / $0
20% / $0
AD
DISCONTINUED
Anthem Blue Cross HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Select HMO**

2-08
HMO
500 / 1000
2250 / 4500
0 visits / $25 copay /
0% co-ins
$15
$25
150 $ded
0%
0% / $0
20% / $0
Saver HMO

2-08
HMO
1500 / 3000
2250 / 4500
0 visits / $20 copay /
0% co-ins
$10
$25
150 $ded
0%
0% / $0
0% / $0
Classic HMO

2-08
HMO
0 / 0
1750 / 3500
0 visits / $20 copay /
0% co-ins
$10
$25
150 $ded
0%
0% / $0
20% / $0
DISCONTINUED
Anthem Blue Cross HMO Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED PLANS
DISCONTINUED
Blue Shield PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Shield Savings 4800

01-2011
PPO
HSA
4800 / 9600
embedded

5900 indiv /
11800 family
embedded

6 Million

0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 2500

01-2011
PPO
HSA
2500 / 5000
embedded

4000 / 8000
embedded

6 million

20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings 3000/6000

01-2011
PPO
HSA
3000 / 6000

4500 / 9000

6 million

0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 2250/4500



01-2011
PPO
HSA
2250 / 4500

4500 / 9000

6 million

20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings 2000/4000

01-2011
PPO
HSA
2000 / 4000

3500 / 7000

6 million

0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings 1800/3600



01-2011
PPO
HSA
1800 / 3600

3000 / 6000

6 million

0% co-ins
AD
$10
$30 or 30%
AD
0%
0% / $0
0% / $0
AD
Shield Savings QS 4800

01-2011
PPO
HSA
4800 /9600

5900 / 11800

6 million

20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings QS 3000/6000

01-2011
PPO
HSA
3000 / 6000

4500 / 9000

6 million

20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Shield Savings QS 2000/4000

01-2011
PPO
HSA
2000 / 4000

3500 / 7000

6 million

20% co-ins
AD
$10
$30 or 30%
AD
20%
20% / $0
20% / $0
AD
Active Choice Plan 750 SG Discontinued

01-2011
PPO

0 / 0

First Dollar Coverage
$750 / $1500

5000 / 10000
100% co-ins up to max copay then many benefits will be 0% co-ins
$15
$30 or 30%
$250 ded
20%
20% / $0
20% / $0
Active Choice Plan 500 SG Discontinued

01-2011
PPO

0 / 0

First Dollar Service
$500 / $1000

5000 / 10000
100% co-ins up to max copay then many benefits will be 0% co-ins
$15
$30 or 30%
$500 ded
30%
30% / $0
30% / $0
Added Advantage POS Plan Discontinued

01-2011
POS
0 / 0

2500 / 5000

None

$25 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Shield Spectrum PPO Plan 3000



01-2011
PPO
3000 / 6000

9000 / 18000

6 million

20% co-ins
$15
$30 or 30%
$500 ded
20%
20% / $0
20% / $250 surgery
AD
Shield Spectrum PPO Plan 2000 Value

01-2011
PPO
2000 per member

7000 per member

6 million

2 visits / $40 copay /
after 2 visits 100% co-ins until max copay has been met - then 0% co-ins

$15
n/a
35%
35% / $0
35% / $500 surgery
AD
Shield Spectrum PPO Plan 1000

01-2011
PPO
1000 / 2000

6000 / 12000

6 million

$45 copay
$10
$30
$250 ded
25%
25% / $0
25% / $500 surgery
AD
Shield Spectrum PPO Plan 500 Premier

01-2011
PPO
500 / 1000

4000 / 8000

6 million

$35 copay
$10
$30
$150 ded
20%
20% / $0
20% / $150 surgery
AD
Shield Spectrum Plan 500 Standard

01-2011
PPO
500 / 1000

4500 / 9000

6 million

$40 copay
$10
$30
250 $ded
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 500 Value

01-2011
PPO
500 indiv / 1000 2 pers / 1500 family

5500 per mem /
11000 2 pers /
16500 family

6 million

$45 copay
$15
$30 or 30%
$250 ded
30%
30% / $0
30% / $250 surgery
AD
Shield Spectrum PPO Plan 250 Premier

01-2011
PPO
250 / 500

2750 indiv /
5500 family

6 million

$15 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
AD
Shield Spectrum PPO Plan 250 Standard

01-2011
PPO
250 / 500

3250 / 6500

6 million

$25 copay
$10
$30
0 $ded
20%
20% / $0
20% / $0
AD
Shield Spectrum PPO Plan, Zero Deductible

01-2011
PPO
0 / 0

2000 / 4000

6 million

$10 copay
$10
$25
0 $ded
10%
10% / $0
10% / $0
PPO(SM) Savings Plan 3400*
Discontinued as of 2-08
2-08
PPO
3400 / 6800
4500 / 9000
$0 copay /
30% co-ins
$10
$30 or 30%
0 $ded
 
DISCONTINUED
Blue Shield HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Access+ HMO Plan 40    Discontinued

01-2011
HMO
0 / 0

4000 / 8000

None

$40 copay
$15
$30
250 $ded
0%
0% / $0
40% / $0
Access+ HMO Plan 30    Discontinued

01-2011
HMO
0 / 0

3500 / 7000

None

$30 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access+ HMO Plan 25    Discontinued

01-2011
HMO
0 / 0

3500 / 7000

None

$25 copay
$15
$30
$250 ded
0%
0% / $0
25% / $0
Access+ HMO Plan 20    Discontinued

01-2011
HMO
0 / 0

2500 / 5000

None

$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access+ HMO Plan 15    Discontinued

01-2011
HMO
0 / 0

2000 / 4000

None

$15 copay
$15
$30
0 $ded
0%
0% / $0
0% / $250 surgery
Access+ HMO Plan 10    Discontinued

1-2011
HMO
0 / 0
2000 / 4000

None
$10 copay
$10
$25
0 $ded
0%
0% / $0
0% / $50 surgery
Access+ HMO Plan 5    Discontinued

01-2011
HMO
0 / 0

1500 / 3000

None

$5 copay
$10
$25
0 $ded
0%
0% / $0
0% / $0
Access+ HMO Plan 20 Value Discontinued

01-2011
HMO
0 / 0

3000 / 6000

None

$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Local Access+ HMO Plan 30 Discontinued

01-2011
HMO
0 / 0

3500 / 7000

None

$30 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Local Access+ HMO Plan 20 Value Discontinued

01-2011
HMO
0 / 0

3000 / 6000

None

$20 copay
$15
$30
$150 ded
0%
0% / $0
0% / $500 surgery
Access Baja® HMO Plan 5

01-2011
HMO
0 / 0
1000 / 2000

None
$5 copay
$5
$5
0 $ded
0%
0% / $0
0% / $25
DISCONTINUED
Blue Shield HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED CALIFORNIA CHOICE PLANS
DISCONTINUED
California Choice Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

None Available

Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED HEALTH NET PLANS
DISCONTINUED Health Net Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options HMO 25 Silver - Plan S5Y

1-09
HMO
0 / 0
3000 / 6000
$25 copay
$15
$30
150 $ded
 
Options HMO 35 Silver - Plan S5Z

5-08
HMO
0 / 0
4000 / 8000
$35 copay
$15
$30
200 $ded
 
DISCONTINUED Health Net Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED KAISER PLANS
DISCONTINUED Kaiser Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
None Available
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED SHARP PLANS
DISCONTINUED
Sharp Plans
Effective
Network
In-Network
(Ded Sgl/Fam)
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)

None Available

Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare
DISCONTINUED UHC PLANS
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Choice Plus Balanced Value 20/3000/90% Plan D6L
3-09
PPO
3000 / 9000
6000 / 12000

5 Million per covered person
$20 copay
$10
$35
$250 ded
10%
10% / $500
10% / $250
AD
Choice Plus Balanced Value 30/2500/80% Plan D6N
3-09
PPO
2500 / 7500
4500 / 9000

5 Million per covered person
$30 copay
$10
$35
$250 ded
20%
20% / $500
20% / $250
AD
Choice Plus Definity HSA 2850/80% Plan D6I
3-09
PPO
2850 / 5600
3500 / 7000

5 Million per covered person
20% co-ins
AD
$10
$30
AD
20%
20% / $0
20% / $0
AD
Choice Plus Definity HSA 2850/80% Plan D6J
3-09
PPO
2850 / 5600
3500 / 7000

5 Million per covered person
20% co-ins
AD
$10
$30
AD
20%
20% / $0
20% / $0
AD
Choice Plus Definity HSA 3000/70% Plan C3X
3-09
PPO
3000 / 6000
5000 / 10000

5 Million per covered person
30% co-ins
AD
$10
$30
AD
30%
30% / $0
30% / $0
AD
Choice Plus Definity HSA 3500/70% Plan C3Y
3-09
PPO
3500 / 7000
5000 / 10000

5 Million per covered person
30% co-ins
AD
$10
$30
AD
30%
30% / $0
30% / $0
AD
Choice Plus Definity HRA 2000/90% Plan C3W
3-09
PPO
2000 / 4000
5000 / 10000

5 Million per covered person
10% co-ins
AD
$10
$35
$250 ded on tiers II & III
10%
10% / $0
10% / $0
AD
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Non Differential PPO 2000/80% Plan 6HE
7-08
PPO
2000 / 6000
4000 / 12000
20% co-ins
   
Choice Plus Balanced 100 30/3000/100% Plan 6CX
7-08
PPO
3000 / 9000
3000 / 9000
$30 copay
   
Choice Plus Balanced 25/1000/80% Plan 6CW
7-08
PPO
1000 / 3000
3500 / 7000
$25 copay
   
Choice Plus Balanced 25/2500/80% Plan 6CV
7-08
PPO
2500 / 7500
4500 / 9000
$25 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Choice Plus Balanced 35/2000/50% Plan 6CN
5-08
PPO
2000 / 6000
6000 / 12000
$35 copay
   
Choice Plus Balanced Value 25/1000/80% Plan 6CP
5-08
PPO
1000 / 3000
3500 / 7000
$25 copay
   
Choice Plus Balanced Value 25/2500/80% Plan 6CQ
5-08
PPO
2500 / 7500
4500 / 9000
$25 copay
   
Choice Plus Balanced Value 35/1000/50% Plan 6CT
5-08
PPO
1000 / 3000
5000 / 10000
$35 copay
   
Choice Plus Balanced Value 35/1000/70% Plan 6CR
5-08
PPO
1000 / 3000
5000 / 10000
$35 copay
   
Choice Plus Balanced Value 35/2000/50% Plan 6CU
5-08
PPO
2000 / 6000
6000 / 12000
$35 copay
   
Choice Plus Balanced Value 40/1500/70% Plan 6CS
5-08
PPO
1500 / 4500
5000 / 10000
$40 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Choice Plus Definity HSA 1500/80% Plan U1O
12-07
PPO
1500 / 3000
3000 / 6000
20% co-ins
   
Non Differential PPO 2000/80% Plan 7CB
12-07
rev 02
PPO
2000 / 6000
4000 / 12000
20% co-ins
   
Choice Plus Balanced 100 30/3000/100% Plan 6CO
12-07
PPO
3000 / 9000
3000 / 9000
$30 copay
   
Choice Plus Balanced 100 30/3000/100% Plan 7AQ
12-07
PPO
3000 / 9000
3000 / 9000
$30 copay
   
Choice Plus Balanced 100 Value 30/3000/100% Plan 6CO
12-07
PPO
3000 / 9000
4000 / 12000
$30 copay
   
Choice Plus Balanced 25/1000/80% Plan 7AB
12-07
PPO
1000 / 3000
3500 / 7000
$25 copay
   
Choice Plus Balanced 25/2500/80% Plan 2AQ
12-07
PPO
2500 / 7500
4500 / 9000
$25 copay
   
Choice Plus Balanced 35/1000/50% Plan 6CE
12-07
PPO
1000 / 3000
5000 / 10000
$35 copay
   
Choice Plus Balanced 35/1000/70% Plan 6CC
12-07
PPO
1000 / 3000
5000 / 10000
$35 copay
   
Choice Plus Balanced 40/1500/70% Plan 6CF
12-07
PPO
1500 / 4500
5000 / 10000
$40 copay
   
Choice Plus Consumer 1500/80% Plan 6CH
12-07
PPO
1500 / 3000
3000 / 6000
20% co-ins
   
Choice Plus Consumer 1500/100% Plan 7AL
12-07
PPO
1500 / 4500
1500 / 4500
0% co-ins
   
Choice Plus Consumer 2000/100% Plan 7AM
12-07
PPO
2000 / 6000
2000 / 6000
0% co-ins
   
Choice Plus Consumer 2500/80% Plan S1Y
12-07
PPO
2500 / 5000
5000 / 10000
20% co-ins
   
Choice Plus Consumer 3000/70% Plan 6CG
12-07
PPO
3000 / 6000
5000 / 10000
30% co-ins
   
Choice Plus Traditional 20/250/90% Plan 6CM
12-07
PPO
250 / 750
3000 / 6000
$20 copay
   
Choice Plus Traditional 30/500/70% Plan 6CB
12-07
PPO
500 / 1500
3000 / 6000
$30 copay
   
Choice Plus Traditional 35/500/80% Plan 6CD
12-07
PPO
500 / 1500
5000 / 10000
$35 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Choice Plus Plan QPA
5-07
PPO
1000 / 3000
3500 / 7000
$25 copay
   
Choice Plus Plan QPB
5-07
PPO
3000 / 9000
3000 / 9000
$30 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
HSA Options PPO Plan LDD
4-06
PPO
2000 / 4000
2000 / 4000
0% co-ins
   
HSA Options PPO Plan LDE
4-06
PPO
2000 / 4000
4000 / 8000
20% co-ins
   
HSA Options PPO Plan LDF
4-06
PPO
2850 / 5600
2850 / 5600
0% co-ins
   
HSA Options PPO Plan LDG
4-06
PPO
2850 / 5600
5000 / 10000
20% co-ins
   
HSA Options PPO Plan LDH
4-06
PPO
2850 / 5600
5000 / 10000
20% co-ins
   
HSA Options PPO Plan LDI
4-06
PPO
3500 / 7000
3500 / 7000
0% co-ins
   
HSA Options PPO Plan LDJ
4-06
PPO
3500 / 7000
5000 / 10000
20% co-ins
   
HSA Options PPO Plan LDK
4-06
PPO
3500 / 7000
5000 / 10000
20% co-ins
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
HSA Options PPO Plan LDL
4-06
PPO
5000 / 10000
5000 / 10000
0% co-ins
   
HSA Options PPO Plan LDM
4-06
PPO
5000 / 10000
5000 / 10000
0% co-ins
   
HSA Options PPO Plan LDN
4-06
PPO
1500 / 3000
1500 / 3000
0% co-ins
   
HSA Options PPO Plan LDO
4-06
PPO
1500 / 3000
3000 / 6000
20% co-ins
   
HSA Options PPO Plan LYA
4-06
PPO
2500 / 5000
2500 / 5000
0% co-ins
   
HSA Options PPO Plan LYB
4-06
PPO
2500 / 5000
5000 / 10000
20% co-ins
   
HSA Options PPO Plan LYC
4-06
PPO
5000 / 10000
5000 / 10000
0% co-ins
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan LKA
4-06
PPO
1500 / 4500
1500 / 4500
$25 copay
   
Options PPO Plan LKB
4-06
PPO
2500 / 7500
2500 / 7500
$25 copay
   
Options PPO Plan LKC
4-06
PPO
3000 / 9000
3000 / 9000
$25 copay
   
Options PPO Plan LKD
4-06
PPO
4000 / 12000
4000 / 12000
$25 copay
   
Options PPO Plan LKE
4-06
PPO
5000 / 15000
5000 / 15000
$25 copay
   
Options PPO Plan LKF
4-06
PPO
1000 / 3000
1000 / 3000
$25 copay
   
Options PPO Plan LKG
4-06
PPO
500 / 1500
3000 / 6000
$25 copay
   
Options PPO Plan LKH
4-06
PPO
1000 / 3000
3500 / 7000
$25 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan LKI
4-06
PPO
2000 / 6000
2000 / 6000
$25 copay
   
Options PPO Plan LKJ
4-06
PPO
500 / 1500
3000 / 6000
$25 copay
   
Options PPO Plan LKK
4-06
PPO
250 / 750
2500 / 5000
$25 copay
   
Options PPO Plan LKL
4-06
PPO
1500 / 4500
4500 / 9000
$25 copay
   
Options PPO Plan NAA
4-06
PPO
250 / 750
1500 / 3000
$20 copay
   
Options PPO Plan NAB
4-06
PPO
250 / 750
1500 / 3000
$20 copay
   
Options PPO Plan NAC
4-06
PPO
500 / 1500
2000 / 4000
$20 copay
   
Options PPO Plan NAD
4-06
PPO
500 / 1500
2000 / 4000
$20 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan NAE
4-06
PPO
1000 / 3000
2500 / 5000
$20 copay
   
Options PPO Plan NAF
4-06
PPO
1000 / 3000
2500 / 5000
$20 copay
   
Options PPO Plan NAG
4-06
PPO
1500 / 4500
3500 / 7000
10% co-ins
   
Options PPO Plan NAH
4-06
PPO
1500 / 4500
3500 / 7000
$25 copay
   
Options PPO Plan NAI
4-06
PPO
1500 / 4500
3500 / 7000
20% co-ins
   
Options PPO Plan NAJ
4-06
PPO
1500 / 4500
3500 / 7000
$25 copay
   
Options PPO Plan NAK
4-06
PPO
2000 / 6000
4000 / 8000
10% co-ins
   
Options PPO Plan NAL
4-06
PPO
2000 / 6000
4000 / 8000
$25 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan NAM
4-06
PPO
2000 / 6000
4000 / 8000
20% co-ins
   
Options PPO Plan NAN
4-06
PPO
2000 / 6000
4000 / 8000
$25 copay
   
Options PPO Plan NAO
4-06
PPO
2500 / 7500
4500 / 9000
10% co-ins
   
Options PPO Plan NAP
4-06
PPO
2500 / 7500
4500 / 9000
$25 copay
   
Options PPO Plan NAQ
4-06
PPO
2500 / 7500
4500 / 9000
20% co-ins
   
Options PPO Plan NAR
4-06
PPO
2500 / 7500
4500 / 9000
$25 copay
   
Options PPO Plan NAS
4-06
PPO
3000 / 9000
5000 / 10000
10% co-ins
   
Options PPO Plan NAT
4-06
PPO
3000 / 9000
5000 / 10000
$30 copay
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan NAU
4-06
PPO
3000 / 9000
5000 / 10000
20% co-ins
   
Options PPO Plan NAV
4-06
PPO
3000 / 9000
5000 / 10000
$30 copay
   
Options PPO Plan NAW
4-06
PPO
5000 / 15000
7500 / 15000
10% co-ins
   
Options PPO Plan NAX
4-06
PPO
5000 / 15000
7500 / 15000
$30 copay
   
Options PPO Plan NAY
4-06
PPO
5000 / 15000
7500 / 15000
20% co-ins
   
Options PPO Plan NAZ
4-06
PPO
5000 / 15000
7500 / 15000
$30 copay
   
Options PPO Plan NDA
4-06
PPO
1000 / 3000
1000 / 3000
$20 copay
   
Options PPO Plan NDB
4-06
PPO
1000 / 3000
1000 / 3000
0% co-ins
   
DISCONTINUED UHC Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits
(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Options PPO Plan NDC
4-06
PPO
2000 / 6000
2000 / 6000
$25 copay
   
Options PPO Plan NDD
4-06
PPO
2000 / 6000
2000 / 6000
0% co-ins
   
Options PPO Plan RUA
4-06
PPO
1100 / 2200
1100 / 2200
0% co-ins
   
Options PPO Plan RUB
4-06
PPO
2000 / 4000
2000 / 4000
0% co-ins
   
Options PPO Plan RUC
4-06
PPO
2850 / 5600
2850 / 5600
0% co-ins
   
Options PPO Plan TEA
4-06
PPO
500 / 1500
2000 / 4000
$20 copay
   
Options PPO Plan TEB
4-06
PPO
1000 / 3000
2500 / 5000
$20 copay
   
Options PPO Plan TEC
4-06
PPO
1500 / 4500
3500 / 7000
$25 copay
   
Options PPO Plan TED
4-06
PPO
1000 / 3000
1000 / 3000
$20 copay
   
Options PPO Plan TEE
4-06
PPO
2000 / 6000
2000 / 6000
$25 copay
   
DISCONTINUED PacifiCare
POS Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SignaturePOS 15/80-60
7-09
POS
0 / 0
2500 / 7500

None
$15 copay
$10
$25
$0 ded
0%
0% / $250 per admit
0% / $250 per admit
DISCONTINUED PacifiCare
PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SV 10-30/500d
3-09
HMO
0 / 0
2000 / 6000

None
$10 copay
$15
$35
150 $ded
0%
0% / $500 per day, 2 day max per admit
0% / $400 per admit
SV Advantage 10-30/500d
3-09
HMO
0 / 0
2000 / 6000

None
$10 copay
$15
$35
150 $ded
0%
0% / $500 per day, max 2 days per admit
0% / $400 per admit
SV 20-40/500d
3-09
HMO
0 / 0
3000 / 9000

None
$20 copay
$20
$35
150 $ded
0%
0% / $500 per day, 4 days max per admit
0% / $400 per admit
SV Advantage 20-40/500d
3-09
HMO
0 / 0
3000 / 9000

None
$20 copay
$20
$35
150 $ded
0%
0% / $500 per day, max 4 days per admit
0% / $400 per admit
SV 35-45/600d
3-09
HMO
0 / 0
5000 / 15000

None
$35 copay
$20
$35
150 $ded
0%
0% / $600 per day, 4 days max per admit
0% / $500 per admit
SV Advantage 35-45/600d
3-09
HMO
0 / 0
5000 / 15000

None
$35 copay
$20
$35
150 $ded
0%
0% / $600 per day, max 4 days per admit
0% / $500 per admit
SignatureElite 20/90-50/250
3-09
PPO
250 / 500
3250 / 6500

5 Million
$20 copay
$10
$35
$150 ded
10%
10% / $0
10% / $0
AD
SignatureElite 30/80-60/250
3-09
PPO
250 / 500
3250 / 6500

5 Million
$30 copay
$10
$35
$150 ded
20%
20% / $0
20% / $0
AD
SignatureElite 30/80-60/500
3-09
PPO
500 / 1000
5500 / 11000

5 Million
$30 copay
$10
$35
$150 ded
20%
20% / $0
20% / $0
AD
SignatureElite 40--50-50--1000
3-09
PPO
1000 / 2000
4000 / 8000

5 Million
$40 copay
$10
$35
$150 ded
50%
50% / $0
50% / $0
AD
SignatureElite 40--70-50--1000
3-09
PPO
1000 / 2000
6000 / 12000

5 Million
$40 copay
$10
$35
$150 ded
30%
30% / $0
30% / $0
AD
SignatureElite 40--70-50--250
3-09
PPO
250 / 500
3250 / 6500

5 Million
$40 copay
$10
$35
$150 ded
30%
30% / $0
30% / $0
AD
SignatureElite 70-50/2000
3-09
PPO
2000 / 4000
5000 / 10000

5 Million
30% co-ins
AD
$10
$35
250 $ded
30%
30% / $0
30% / $0
AD
SignatureElite 70-50/3500
3-09
PPO
3500 / 7000
5500 / 11000

5 Million
30% co-ins
AD
$10
$35
250 $ded
30%
30% / $0
30% / $0
AD
DISCONTINUED PacifiCare
PPO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SignatureElite 30/70-50/250
7-07
PPO
250 / 500
3000 / 6000
0 visits / $20 copay /
0% co-ins
$10
$35
150 $ded
 
SignatureElite 35/80-60/500
7-07
PPO
500 / 1000
5000 / 10000
0 visits / $35 copay /
0% co-ins
$10
$35
0 $ded
 
SignatureElite 35/70-50/1000
7-07
PPO
1000 / 2000
5000 / 10000
0 visits / $35 copay /
0% co-ins
$10
$35
0 $ded
 
SignatureElite 35/50-50/1000
7-07
PPO
1000 / 2000
3000 / 6000
0 visits / $35 copay /
0% co-ins
$10
$35
0 $ded
 
DISCONTINUED HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
15/90-50/250
3-07
PPO
250 / 500
3000 / 6000
0 visits / $15 copay /
0% co-ins
$10
$25
0 $ded
 
20/80-60/250
3-07
PPO
250 / 500
3000 / 6000
0 visits / $20 copay /
0% co-ins
$10
$25
0 $ded
 
DISCONTINUED HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SV Advantage 20/1500ded
7-06
HMO
1500 / 3000
4000 / 8000
0 visits / $20 copay /
0% co-ins
$20
$35
0 $ded
 
SV Advantage 35/600d
7-06
HMO
0 / 0
5000 / 15000
0 visits / $35 copay /
0% co-ins
$15
$35
0 $ded
 
DISCONTINUED HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SV Advantage 10-30/100
6-06
HMO
0 / 0
1500 / 4500
0 visits / $10 copay /
0% co-ins
$10
$25
0 $ded
 
SV Advantage 15-30/250a
6-06
HMO
0 / 0
1500 / 4500
0 visits / $15 copay /
0% co-ins
$10
$25
0 $ded
 
DISCONTINUED PacifCare HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
SV 15-30/250a
2-06
HMO
0 / 0
1500 / 4500
0 visits / $15 copay /
0% co-ins
$10
$25
0 $ded
 
SV Advantage 10/500d
2-06
HMO
0 / 0
2000 / 6000
0 visits / $10 copay /
0% co-ins
$15
$35
0 $ded
 
DISCONTINUED PacifiCare
HMO Plans
Effective
Network
In-Network
Ded Sgl/Fam
In-Network
Out/pocket max

Lifetime Max
In-Network
Office visits

(AD = after deductible)
Rx Drugs...
Generic
Brand Name
Deductible

(AD = after deductible)
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible)
Old/Discontinued Plans (CA):
Aetna  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  Health Net  |  Kaiser  |  Sharp  |  UHC / PacifiCare