Platinum Platinum 90
Highest coverage plan with 90% actuarial value
Cost Overview
Annual Deductible
$0
Out-of-Pocket Maximum
$5,000
Standardized Benefits
| Service | You Pay | Notes |
|---|---|---|
| Deductibles | ||
| Individual Deductible (Medical) | $0 | |
| Individual Deductible (Pharmacy) | $0 | |
| Family Deductible (Medical) | $0 | |
| Family Deductible (Pharmacy) | $0 | |
| Care Visits | ||
| Preventive Care | no charge | |
| Primary Care Visit | $15 | |
| Urgent Care Visit | $15 | |
| Specialty Care Visit | $30 | |
| Mental/Behavioral Health Visit | $15 | |
| Tests & Therapy | ||
| Other Therapy (PT/OT/Speech) | $15 | |
| Lab Testing | $15 | |
| X-rays & Diagnostic Imaging | $30 | |
| Advanced Imaging (CT/MRI) | $75 or 10% | |
| Hospital & Emergency | ||
| Outpatient Surgery | $95 or 10% | |
| Emergency Room | $175 | |
| Emergency Transport | $150 | |
| Prenatal/Postnatal Care | no charge | |
| Inpatient Hospital Stay | $225 per day up to 5 days or 10% | |
| Hospital Physician | $0 or 10% | |
| Prescription Drugs | ||
| Generic Drugs (Tier 1) | $9 | |
| Preferred Brand Drugs (Tier 2) | $16 | |
| Non-Preferred Brand Drugs (Tier 3) | $25 | |
| Specialty Drugs (Tier 4) | 10% up to $250 | |
| Out of Pocket Maximums | ||
| Maximum Out of Pocket (Individual) | $5,000 | |
| Maximum Out of Pocket (Family) | $10,000 | |
Understanding Deductibles and Benefit Costs
Benefits in Orange are Subject to the Annual Deductible amounts listed above. You will pay the full cost for these services until the Deductible is met. Then you will pay the specified amount that is shown until the Annual Maximum Out-of-Pocket is met. The deductible counts toward the Maximum Out-Of-Pocket.
Copays in Black are NOT Subject to any Deductible and count towards the Annual Maximum Out-Of-Pocket. The Annual Out-Of-Pocket Maximum and Deductible amounts are always based on the Individual amount listed even under a family plan. Two or more people in the family have to reach the family amounts listed above in order for them to apply to the entire family.
Understanding Your Benefits
- Copay: A fixed amount you pay for a covered service.
- Coinsurance: Your share of costs after meeting your deductible (shown as a percentage).
- Deductible: The amount you pay before your insurance starts covering costs.
- Out-of-Pocket Maximum: The most you'll pay in a year for covered services.
Important: Copays vs. Coinsurance — Your Costs May Vary
The amounts shown above are standardized benefit summaries and may not reflect your actual out-of-pocket costs. HMO plans typically charge fixed copay amounts (e.g., $75 for an MRI), while PPO plans typically use coinsurance percentages (e.g., 25% of the total cost) — which can result in significantly higher out-of-pocket costs for expensive services like MRIs, surgeries, and hospital stays. Some HMO plans (such as Molina and certain Gold 80 Coinsurance plans) also use coinsurance percentages instead of flat copays.
Tip: Before switching plans — especially at the Gold and Platinum tiers — review your specific plan's Summary of Benefits and Coverage (SBC) document, or contact one of our licensed agents for personalized guidance on which plan best fits your healthcare needs.