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Ventura Orthopedics
2021 Employee Benefits Brochure

Medical Plans

Blue Shield Full PPO Combined Deductible 25-2500

In- Network Out-of-Network

Deductible:
Individual $2,500 $2,500
Family $5,000 $5,000

Calendar Year Out-of-Pocket Maximum:
Individual $6,850 $10,500
Family $13,700 $21,000

Hospital Services:
Inpatient 20%* 50%*-Max $600/day
+100% additional services
Outpatient Surgery 10%* 50%*-Max $350/day
+100% additional services
Emergency Room $150/visit + 20% $150/visit + 20%
(copay waived if admitted)

Physician Services:
Office Visit (PCP/Specialist) $25/$25 50%*
Diagnostic Lab & X-Ray $25/visit 50%*
Imaging (CT/PET scans, MRIs) $25/visit 50%*
Urgent Care $25/visit 50% *
Acupuncture\Chiropractic (limit 20 visits) $25/visit 50%*
Teledoc Consultation $0/consult Not Covered

Routine Care:
Preventative Checkups No Charge Not Covered
Pre-Natal Maternity 20% * 50%*

Prescription Drugs:
Tier 1 (Deductible waived) $15 retail/$30 mailorder 25% of price + $15/RX, mail order -N/A
Tier 2 $30 retail/$60 mailorder 25% of price + $30/RX, mail order -N/A
Tier 3 $45 retail/$90 mail order 25% of price + $45/RX, mail order -N/A
Tier 4 (Specialty Drugs) 30% up to $250 per RX Not Covered
DME (Durable Medical Equipment) 20%* 50%*

Pharmacy Deductible: $150 Calendar Year per member
Retail Rx: Up to a 30 day supply from Blue Shields RX Ultra Network
Mail Oder Rx: up to 90 day supply from Blue Shields RX Ultra Network
*after deductible

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