City Care Benefits Medical Plans
(for those with San Diego business licenses only)

Authorized Agent
#0D40575

PacifiCare High Option Plan HMO:

• $15 Office Visit
• 100% PA Hospital
• $50 Emergency Room
• Mental Health $15 Office Visit
• Prescription Drug Coverage
• Generic Drugs - $20
• Brand Formulary Drugs - $30
• Non-Formulary Drugs - $50

PacifiCare Medium Option Plan HMO:

• $20 Office Visit/$40 Specialist
• $250 PA Hospital
• $100 Emergency Room
• Mental Health $20 Office Visit
• Prescription Drug Coverage
• Generic Drugs - $20
• Brand Formulary Drugs - $30
• Non-Formulary Drugs - $50

PacifiCare Low Option Plan HMO:

• $15 Office Visit/$30 Specialist
• 80% Hospital up to $2,000 Individual/$6,000 Family
• $100 Emergency Room
• Mental Health $20
• Prescription Drug Coverage
• Generic Drugs - $20
• Brand Formulary Drugs - $30
• Non-Formulary Drugs - $50

Riders Available:

• Golden West PPO Dental
• Golden West HMO Dental
• Golden West Voluntary Dental
• Golden West and Safeguard Vision
• American Specialty Health Plan (options include Chiropractic and/or Acupuncture)
• Mutual of Omaha Term Life (options also include a Travel Assistance Program)