Page 11 - Optima Tax EE Guide 01-19 CA_FINAL
P. 11

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.





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