Page 11 - Remita Guide 2020 - CA FINAL

Blue Shield Blue Shield
Savings PPO HSA PPO
Network Name Network Non-Network Network Non-Network
Health Benefits
Deductible (Annual)
- Individual (EE Only) $1,500 $1,500 $500 $1,500
- Individual (Family Plan) $2,800 $2,800 $500 $1,500
- Family $3,000 $3,000 $1,500 $4,500
Co-Insurance (Plan Pays) 90% 60% 80% 60%
Office Visit Copay
- Primary Care Physician Deductible, 10% Deductible, 40% $20 Copay Deductible, 40%
- Specialist Office Visit Deductible, 10% Deductible, 40% $20 Copay Deductible, 40%
Out-of-Pocket Maximum
- Individual $3,500 $6,000 $3,000 $5,000
- Family $7,000 $12,000 $6,000 $10,000
Hospitalization
- Inpatient Deductible, 10% Deductible, 40% Max Deductible, 20% Deductible, 40% Max
$600/day $600/day
- Outpatient Deductible, 15% Deductible, 40% Deductible, 25% Deductible, 40%
- Ambulatory Surgery Center Deductible, 5% Deductible, 40% Deductible, 10% Deductible, 40%
Lab and X-Ray Deductible, 10% Deductible, 40% Deductible, Deductible, 40%
$20 Copay
Emergency Services $150 Copay, Deductible, 10% $150 Copay, 20%
Urgent Care Deductible, 10% Deductible, 40% $20 Copay Deductible, 40%
Chiropractic Deductible, 10% Deductible, 40% $25 Copay Deductible, 40%
Max 20 Visits/Year Max 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible Does not apply to Tier 1 Does not apply to Tier 1
- Individual Health Deductible Health Deductible $150 / Member $150 / Member

Retail Pharmacy
- Tier 1 Ded, $10 Copay Ded, $10 Copay, 25% $15 Copay $15 Copay, 25%
- Tier 2 Ded, $25 Copay Ded, $25 Copay, 25% Ded, $30 Copay Ded, $30 Copay, 25%
- Tier 3 Ded, $40 Copay Ded, $40 Copay, 25% Ded, $45 Copay Ded, $45 Copay, 25%
- Tier 4 Ded, 30% up to $200 Ded 30% up to $200, Ded, 30% up to Ded, 30% up to $200,
- Supply Limit 30 Days 25% $200 25%
30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 Ded, $20 Copay Not Covered $30 Copay Not Covered
- Tier 2 Ded, $50 Copay Not Covered Ded, $60 Copay Not Covered
- Tier 3 Ded, $80 Copay Not Covered Ded, $90 Copay Not Covered
- Tier 4 Ded, 30% up to $400 Not Covered Ded, 30% up to $400 Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

Summary of Benefits and Coverage (SBC)