Page 6 - Arktura EE Guide 12-17 - Final Sent 11.3.17

BENEFITS

MEDICAL INSURANCE

BLUE SHIELD KAISER BLUE SHIELD
PLAN NAME SILVER TRIO ACO HMO SILVER 70 HMO GOLD HMO 500
Network Name Trio Kaiser Only Access+
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $1,700 $1,000 $500
- Family $3,400 $2,000 $1,000

Co-Insurance (You Pay) 40% 30% 20%
Office Visit Copay
- Primary Care Physician $55 Copay $50 Copay $35 Copay
- Specialist Office Visit $85 Copay $50 Copay $55 Copay
Out-of-Pocket Maximum
- Individual $6,800 $6,750 $5,600
- Family $13,600 $13,500 $11,200

Hospitalization
- Inpatient Ded, 40% Ded, 30% Ded, 20%
- Outpatient Ded, 40% Ded, 30% Ded, 20%
Lab and X-Ray (Complex) $55 Copay (Ded, $250) $50 Copay (Ded, 30%) $50 Copay (Ded, $250)

Emergency Services Ded, $275 Copay Ded, 30% Ded, $250 Copay
Urgent Care $55 Copay $50 Copay $35 Copay
Preventive Care No Charge No Charge No Charge
Chiropractic $15 Copay $15 Copay $15 Copay

15 Visits/Year 20 Visits/Year 15 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $275 $200 None
- Family $550 $400 None

Retail Pharmacy
- Generic Formulary $15 Copay $25 Copay $15 Copay
- Brand Name Formulary $55 Copay $50 Copay $30 Copay
- Non-Formulary $75 Copay $50 Copay $50 Copay
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay $50 Copay $30 Copay
- Brand Name Formulary $110 Copay $100 Copay $60 Copay
- Non-Formulary $150 Copay $100 Copay $100 Copay
- Supply Limit 90 Days 90 Days 90 Days

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