| Benefits | COVA Care You Pay |
COVA HDHP You Pay |
Kaiser Permanente You Pay |
| Deductible - per plan year - One person - Two or more persons |
$200 $400 |
$1,200 $2,400 |
None None |
| Out-of -pocket expense limit - per plan year One person Two or more persons |
$1,500 $3,000 |
$5,000 $10,000 |
None None |
| Doctor's visits Primary Care Physician Specialist |
$25 $35 |
20% after deductible 20% after deductible |
$10 $10 |
| Hospital Services Inpatient Outpatient |
$300 per stay $100 per visit |
20% after deductible 20% after deductible |
$100 per admission $10 per visit |
| Emergency Room Visits |
$100 per visit (waived if admitted) |
20% after deductible |
$50 per visit (waived if admitted) |
| Outpatient diagnostic laboratory, test, shots and x-rays |
10% after deductible |
20% after deductible |
$10 physician, x-ray and diagnostic services $0 copayment lab, pathology, radiology, diagnostic testing |
| Prescription drugs - mandatory generic Retail Pharmacy |
Up to 34-day supply: $15/$20/$35 |
20% after deductible 20% after deductible |
Up to 60-day supply - Kaiser On-Site Pharmacy $10 - Community Pharmacy $20 |
| Home Delivery Pharmacy | Up to 90-day supply: $30/$40/$70 |
20% after deductible |
Up to 90-day supply Mail Service $8 |
| Diabetic test strips and glucose monitors | 20%, no deductible |
20% after deductible |
Test strips 20%, no deductible Glucose monitors $10 |
| Wellness & Preventive Services Through age 6 (Office visits at specified intervals, immunizations, lab and x-rays) |
$0 |
$0 |
$0 (up to age 5) |
| Age 7 and older (Annual checkup visit- Primary Care Physician or Specialist) Immunizations, lab and x-rays |
$0 $0 |
$0 $0 |
$10 $0 |
| Specified ages (Routine gynecological exam, Pap test, mammography screening, prostate exam (digital rectal exam), prostate specific antigen test (PSA), and other colorectal cancer screening |
$0 |
$0 |
$0 |
| Dental -per plan year | Basic No deductible Plan pays up to $1,200 per member |
Expanded - $25 deductible per member up to $75 per family - Plan pays up to $1,500 per member |
Expanded In-plan:$25 deductible per member; plan pays up to $1,000 per member |
| Out - of -Network | Buy-up available | Not available | Not available |
| Expanded Dental | Buy-up available | Included | Included |
| Vision & Hearing | Buy-up available | Not available | Routine vision only |
| This is an overview of your health care benefits. For details, see the appropriate Member Handbook or plan document. | |||