Page 11 - Optima Tax EE Guide 01-19 CA_FINAL

Medical Plan Highlights

Blue Shield Blue Shield
Plan Name PPO High PPO Low

Blue Shield Blue Shield
Network Name of CA PPO Non-Network of CA PPO Non-Network
Plan Differences
Employee Premiums $$$ $$

Employee Cost Sharing Contribution, Deductible, Contribution, Deductible,
Copay, Coinsurance Copay, Coinsurance
Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits ✓ ✓
Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Max Benefit Unlimited Unlimited

Deductible (Cal Year)
- Individual $250 $2,000
- Family $500 $4,000
Out-of-Pocket Maximum
- Individual $3,750 $10,250 $6,000 $9,000
- Family $7,500 $20,500 $12,000 $18,000
Coinsurance (Plan Pays) 80% 60% 80% 50%
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- PCP $20 Copay Deductible, 40% $20 Copay Deductible, 50%
- Specialist $20 Copay Deductible, 40% $20 Copay Deductible, 50%
- Urgent Care $20 Copay Deductible, 40% $20 Copay Deductible, 50%
- Virtual Visits: Teladoc $5 Copay N/A $5 Copay N/A
- House Calls: Heal $20 Copay N/A $20 Copay N/A
24/7 Nurseline No Charge N/A No Charge N/A
Hospitalization
- Inpatient Deductible, 20% Deductible, 40%* Deductible, Deductible, 50%*
$100 Copay, 20%
- Outpatient Surgery Deductible, 10%-25% Deductible, 40%* Deductible, 10%-25% Deductible, 50%*
Lab and X-Ray
- Diagnostic Deductible, Deductible, 40%* Deductible, Deductible, 50%*
$20-$45 Copay $20-$45 Copay
- Radiological/Nuclear Deductible, 20% Deductible, 40%* Deductible, 20% Deductible, 50%*

Emergency Room $150 Copay, 20% $150 Copay, 20%
Services
Chiropractic $25 Copay Deductible, 40% $25 Copay Deductible, 50%
Max 20 Visits/Year
Acupuncture Deductible, Deductible, 40% Deductible, Deductible, 50%
Max 20 Visits/Year $25 Copay $25 Copay
*Limitations apply for non-network hospital and lab/x-ray. See SBC for details.

Employee Benefits 11