Page 5 - Catasys Benefit Guide 2019-2020

Medical Benefits

Medical Insurance

Blue Shield Blue Shield Blue Shield
HMO High PPO Low PPO
(Only available
Medical Benefits in California)
Sub Plan Platinum Access+ Platinum Full PPO Non-Network Silver Full PPO Non-Network
HMO 0/25 250/15 1700/55
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual None $250 $500 $1,700 $3,400
- Family None $500 $1,000 $3,400 $6,800
Co-Insurance (Plan Pays) 100% 90% 60% 65% 50%

Office Visit Copay
- Primary Care Physician $25 Copay $15 Copay 60% $55 Copay 50%
- Specialist Office Visit $50 Copay $30 Copay 60% $70 Copay 50%
Lab and X-Ray $20/$50 90%/90% 60% 65%/65%
Complex Radiology $200 - performed 90% $100 - per- $100 - performed 50%
(CT, MRI, PET) - Prior in hospital formed in hos- in hospital
Authorization Required $50 - free pital 65% - free
standing center 65% - free standing center
standing center
Out-of-Pocket Maximum
- Individual $1,700 $3,600 $8,000 $7,000 $10,000
- Family $3,400 $7,200 $16,000 $14,000 $20,000

Hospitalization $250 Copay 90% 60% (Limited to 65% 50% (Limited to
(3 Day Copay Max) $2,000 Per Day) $2,000 Per Day)
Emergency Services $250 Copay $100 Copay + 90% $200 Copay + 65%

Urgent Care $25 Copay $15 Copay 60% $40 Copay Not Covered
Preventive Care 100% 100% Not Covered 100% Not Covered
Chiropractic $15 Copay 50%, Ded Waived 50% Ded Waived
15 Visits/Calendar 12 Visits/Calendar Year 12 Visits/Calendar Year
Year

Acupuncture $15 Copay $25 Copay 60% $25 Copay 50%
Pharmacy Benefits
Retail Pharmacy
- Tier 1 $5 Copay $5 Copay Not Covered $15 Copay Not Covered
- Tier 2 $15 Copay $30 Copay Not Covered $50 Copay Not Covered
- Tier 3 $25 Copay $50 Copay Not Covered $75 Copay Not Covered
- Supply Limit 30 Days 30 Days N/A 30 Days N/A

Mail Order Pharmacy
- Tier 1 $10 Copay $10 Copay Not Covered $30 Copay Not Covered
- Tier 2 $30 Copay $60 Copay Not Covered $100 Copay Not Covered
- Tier 3 $50 Copay $100 Copay Not Covered $150 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A 90 Days N/A
Deductible - Ind./Family None None N/A $300/$600 N/A

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