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| San Francisco Trial Lawyers Association |
| You can choose from two EOA Benefit Plans | |||
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| Health Net | Health Net | ||
| Elect Open Access 10 | Elect Open Access 20 | ||
| Benefits | In-Network | In-Network | |
| Insured Co-pay & Negotiated Fee 1 | Insured Co-pay & Negotiated Fee 1 | ||
| OUT-OF-POCKET (Ind/Fam) | $1,500/$3,000 | $2,000/$4,000 | |
| LIFETIME MAXIMUM | Unlimited | Unlimited | |
| PHYSICIAN OFFICE VISITS | $10 Insured Co-payment | $20 Insured Co-payment | |
| SPECIALIST OFFICE VISITS | $25 PPO Self Referral Insured Co-payment | $35 PPO Self Referral Insured Co-payment | |
| LAB/X-RAY | 100% | 100% | |
| COMPLEX RADIOLOGY (CT, MRI) | $100 Insured Co-payment | $100 Insured Co-payment | |
| OUTPATIENT SURGERY | 100% | $250 Insured Co-payment per surgery2 | |
| INPATIENT HOSPITAL | 100% | $250 Insured Co-payment per admission (3 day max) | |
| EMERGENCY CARE | $100 Insured Co-payment | $100 Insured Co-payment | |
| - Per Occurrence | The Insured Co-payment is Waived If Admitted | The Insured Co-payment is Waived If Admitted | |
| PREVENTIVE CARE | |||
| Well Woman Exam Office Visit | $10 Insured Co-payment | $20 Insured Co-payment | |
| Prescriptions - Outpatient | |||
| Pharmacy - 30 Days | Generic $10 | Generic $15 | |
| Brand $25 | Brand $30 | ||
| Non-Formulary $50 | Non-Formulary $50 | ||
| Mail Order - 90 Days | Generic $20 | Generic $30 | |
| Brand $50 | Brand $60 | ||
| Non-Formulary $100 | Non-Formulary $100 | ||
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1 Member will pay
amounts with $ sign shown; Carrier will pay amounts where % sign is
shown unless otherwise noted. 2 Facility services other than surgery 20% coinsurance applies. |
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| -This information is for illustrative purposes and is not intended to present complete details. Actual terms are governed by the master policies. | |||
