Page 4 - MarketCast 2021 EB Brochure - California
P. 4
Blue Shield Medical Plans
Access + Full PPO Split Ded Full PPO Split Ded Full PPO Savings
HMO*** 35-100* 20-500* H.S.A.*
Deductible:
Individual none $1,000 $500 $3,000
Family none $3,000 $1,500 $6,000
Annual Out of Pocket
Maximum:
Individual $2,500 $5,500 $3,000 $5,500
Family $5,000 $11,000 $6,000 $11,000
Hospital Services:
Inpatient $500 per admin 20% coinsurance** 20% coinsurance** 20% coinsurance**
Outpatient Surgery $100 per surgery 10% coinsurance** 10% coinsurance** 10% coinsurance**
Emergency Room $100 per visit $150 per admission $150 per admission $150 per admission
+20% co-ins +20% co-ins +20% co-ins**
Physician Services:
Office Visit
(PCP/Specialist) $20 / $30 $35 / $35 $20 / $20 20% coinsurance**
Urgent Care $20 $35 $20 20% coinsurance**
Preventive Care: No charge No charge No charge No charge
Prescription Drugs:
Rx Deductible None None None Combined with medical
Tier 1 $15 $15 $15 $10**
Tier 2 $30 $30 $30 $25**
Tier 3 $45 $45 $45 $40**
Tier 4 20% coinsurance 30% coinsurance up 30% coinsurance up 30% coinsurance up to
up to $500 per Rx to $500 per Rx to $500 per Rx $500 per Rx**
*Please refer to carrier benefit summaries for more detailed information & out-of-network benefits
**Deductible applies
***The Access+ HMO plan is only offered to those in California
MarketCast 2021 Employee Benefits Brochure Page 3
