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2021 Plans & Benefits

Western Health Advantage (HMO)

Plan Highlights
Your Benefits Your Cost
Hospital (inpatient and outpatient) No cost1
Office visits (primary care physicians and specialist) $15 per visit
Diagnostic x-ray and laboratory services No cost
Ambulance No cost
Urgent Care Virtual Visit/Urgent Care Center $15/$15 per visit
Emergency room $50 per visit2
Chiropractic $15 per visit3
Acupuncture $15 per visit3
1Except for $15/visit for physical, occupational, and speech therapy performed on an outpatient basis. 2Waived if hospitalized as an inpatient or for observation as an outpatient. 3Up to 20 combined visits in a calendar year.
 Annual Out of Pocket  Maximum
Individual $1,500 Family $3,000

 


Region 1
State Employees and Retired Annuitants Monthly Rates*
Single 2-Party Family
$757.02 $1,514.04 $1,968.25
 
Contracting Agency Employees and Retired Annuitants Monthly Rates*
Single 2-Party Family
$757.02 $1,514.04 $1,968.25

 


PDF Downloads

Evidence of Coverage and Benefits Matrix

Evidence of Coverage & Benefits Matrix

Summary of Benefits and Coverage

Summary of Benefits & Coverage

Open Enrollment Booklet

Open Enrollment Booklet


*Posted rates do not reflect employer contribution amounts.

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