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Coverage levels
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2016 Covered California Health Insurance Plans

Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers compared with what you are expected to pay in co-pays and deductibles. Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.

Read more about coverage basics:

Providing Information During the Application Process

Applicants will be asked to provide information about the members in their household who will be covered, as well as their home ZIP code and other details. In accordance with federal law, if consumers are seeking potential federal premium assistance, they will be asked to provide information during the enrollment process to verify income, citizenship and residency. This information includes:

Card Number: ZZZ9999999999.

Expiration Date: 12/31/9999.

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2016 STANDARD BENEFIT DESIGNS BY METAL TIER

MEDICAL COST SHARES
Coverage Category Bronze Silver Gold Platinum
Covers 60% average annual cost >Covers 70% average annual cost Covers 80% average annual cost Covers 90% average annual cost
Annual Wellness Exam $0 $0 $0 $0
Primary Care Visit $70 $45 $35 $20
Specialty Care Visit $90* $70 $55 $40
Urgent Care Visit $120* $90 $60 $40
Emergency Room Facility Full cost until out-of-pocket maximum is met $250 once medical deductible is met $250 $150
Laboratory Tests $40 $35 $35 $20
X-Ray and Diagnostics Full cost until out-of-pocket maximum is met $65 $50 $40
Deductible
  • Individual: $6,000 medical $500 drug
  • Family: $12,000 medical $1,000 drug
  • Individual: $2,250 medical $250 drug
  • Family: $4,500 medical $500 drug.
N/A N/A
Annual Out-of-Pocket Maximum $6,500 individual and $13,000 family $6,250 individual and $12,500 family $6,200 individual and $12,400 family $4,000 individual and $8,000 family

Benefits shown in blue are not subject to a deductible.

*Copay is for any combination of the first three visits. After three visits they will be at full cost until the out-pocket-maximum is met.

DRUG COST SHARES - 30 DAY SUPPLY
Generic Drugs (Tier 1) up to $500, after deductible is met $15 or less $15 or less $15 or less
Preferred Drugs (Tier 2) up to $500, after deductible is met $50 after drug deductible $50 or less $15 or less
Non-preferred Drugs (Tier 3) up to $500, after deductible is met $70 after drug deductible $70 or less $25 or less
Specialty Drugs (Tier 4) up to $500, after deductible is met 20% up to $250 after drug deductible 20% up to $250 10% up to $250
 

2016 STANDARD BENEFIT DESIGNS BY INCOME

MEDICAL COST SHARES
Coverage Category Enhanced Silver 94 Enhanced Silver 87 Enhanced Silver 73
Eligibility Based on Income and Premium Assistance Covers 94% average annual cost Covers 87% average annual cost Covers 73% average annual cost
Single Income Ranges up to $17,655 (≤150%FPL) $17,656 to $23,450 (>150% to ≤200% FPL) $23,451 to $29,425 (>200% to ≤250% FPL)
Annual Wellness Exam $0 $0 $0
Primary Care Visit $5 $15 $40
Specialist Visit $8 $25 $55
Urgent Care Visit $6 $30 $80
Laboratory Tests $8 $15 $35
X-Ray and Diagnostics $8 $25 $50
Imaging $50 $100 $250
Deductible
  • Individual: $75 medical
  • Family: $150 medical
  • Individual: $550 medical $50 drug
  • Family: $1,100 medical $100 drug
  • Individual: $1,900 medical $250 drug
  • Family: $3,800 medical $500 drug
Annual Out-of-Pocket Maximum $2,250 individual and $4,500 family $2,250 individual and $4,500 family $5,450 individual and $10,900 family
DRUG COST SHARES - 30 DAY SUPPLY
Generic Drugs (Tier 1) $3 or less $5 or less $15 or less
Preferred Drugs (Tier 2) $10 or less $20 after drug deductible $45 after drug deductible
Non-preferred Drugs (Tier 3) $15 or less $35 after drug deductible $70 after drug deductible
Specialty Drugs (Tier 4) 10% up to $150 15% up to $150 after drug deductible 20% up to $250 after drug deductible

Benefits shown in blue are not subject to a deductible.