Page 6 - Westmark BG 2020

Medical Benefits

Plan Features Blue Shield HMO
Platinum Access+ HMO Platinum Trio HMO

Network Access+ HMO (Full HMO) Trio HMO (Limited HMO)

Deductible (Annual)
- Individual/Family None None

Out of Pocket Maximum $1,900 / $3,800 $1,900 / $3,800
- Individual/Family (embedded, includes deductible) (embedded, includes deductible)

Physician Services
- Office Visits $20/$40 (deductible waived) $20/$40 (deductible waived)
- Preventive Care No charge No charge
- Teledoc consultation $5 per consultation (deductible waived) $5 per consultation (deductible waived)
- Diagnostic Lab/X-Ray Lab& Path: $10 (deductible waived) Lab& Path: $10 (deductible waived)
- Imaging Outpatient Radiology Center: $30; Outpatient Radiology Center: $30;
Outpatient Hospital $100 (deductible waived) Outpatient Hospital $100 (deductible waived)
- Rehab (Visit limits apply) $20 (deductible waived) $20 (deductible waived)
- Chiropractic Care (Visit $15 (deductible waived) $15 (deductible waived)
limits apply)

Hospitalization
- Inpatient $500/admit $500/admit
- Outpatient $150/admit $150/admit

Mental Health & Substance

Abuse $500/admit $500/admit
- In-Patient $150/admit $150/admit
- Out-Patient

Emergency Services
- Emergency Room $200 copay (waived if admitted) $200 copay (waived if admitted)
- Ambulance Transport $150 (deductible waived) $150 (deductible waived)
- Urgent Care $20 $20
Maternity
- Prenatal Care No charge No charge
- Postnatal Care No charge No charge
- Inpatient Delivery $500/admit $500/admit

Prescription Drugs
Deductible (Subject to Tiers
2-4)
- Tier 1: Generic $5 copay Level A: $5 copay; Level B: $10 copay
- Tier 2: Preferred Brand $15 copay Level A: $15 copay; Level B: $30 copay
- Tier 3: Non-Preferred $25 copay Level A: $25 copay; Level B: $45 copay
Brand 20% up to $250 20% up to $250
- Tier 4: Specialty 30 Days 30 Days
Supply Limit 2 times retail $10/$30/$50
Mail Order Pharmacy 90-days 90-days
Mail Order Supply Limit

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