Page 5 - VO 2021 Employee Benefits_No Notices

Ventura Orthopedics
2021 Employee Benefits Brochure

Medical Plans

Blue Shield Full PPO Savings Embedded Deductible 4000

In- Network Out-of-Network

Deductible: (Combined medical and
pharmacy deductible)
Individual $4,000 $4,000
Individual/Family $4,000/$8,000 $4,000/$8,000

Calendar Year Out-of-Pocket Maximum:
Individual $6,000 $10,000
Family $12,000 $20,000

Hospital Services:
Inpatient 20%* 50%*-Max $600/day
+100% additional services
Outpatient Surgery 20%* 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) 20%* 50%*
Diagnostic Lab & X-Ray 20%* 50%*
Imaging (CT/PET scans, MRIs) 20%* 50%*
Urgent Care 20%* 50%*
Acupuncture\Chiropractic (limit 20 visits) 20%* 50%*
Teledoc Consultation $0/Consult Not Covered

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

Prescription Drugs:
Tier 1 $10 retail/$20 mailorder* 25%* + $10/RX , mail order -N/A
Tier 2 $15 retail/$30 mailorder* 25%* + $15/RX , mail order -N/A
Tier 3 $30 retail/$60 mail order* 25%* + $30/RX , mail order -N/A
Tier 4 (Specialty Drugs) 30%-Max, up to $250/RX* 30%-Max, up to $250/RX*
DME (Durable Medical Equipment) 20%* 50%*

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

H.S.A- Health savings account is a tax-exempt savings account that, when paired with a qualified high-deductible plan (HDHP),
can be used to pay for certain medical expenses.

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