Page 7 - Arktura EE Guide 12-17 - Final Sent 11.3.17

BENEFITS

MEDICAL INSURANCE

BLUE SHIELD BLUE SHIELD
PLAN NAME GOLD PPO 750/20 PLATINUM PPO 150/15
Network Name Full PPO Non-Network Full PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $750 $1,500 $150 $300
- Family $1,500 $3,000 $300 $600

Co-Insurance (You Pay) 20% 40% 10% 40%
Office Visit Copay
- Primary Care Physician $20 Copay Ded, 40% $15 Copay Ded, 40%
- Specialist Office Visit $35 Copay Ded, 40% $30 Copay Ded, 40%

Out-of-Pocket Maximum
- Individual $6,500 $10,000 $3,000 $8,000
- Family $13,000 $20,000 $6,000 $16,000
Hospitalization
- Inpatient Ded, 20% Ded, 40% Ded, 10% Ded, 40%
- Outpatient Ded, 20% Ded, 40% Ded, 10% Ded, 40%

Lab and X-Ray Ded, 20% Ded, 40% Ded, 10% Ded, 40%
Emergency Services Ded, $100 Copay, 20% Ded, $100 Copay, 10%
Urgent Care $20 Copay Not Covered $15 Copay Not Covered

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic 50% 50% 50% 50%

12 Visits/Year 12 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $200 N/A None N/A
- Family $400 N/A None N/A

Retail Pharmacy
- Generic Formulary $10 Copay Not Covered $5 Copay Not Covered
- Brand Name Formulary $30 Copay Not Covered $30 Copay Not Covered
- Non-Formulary $50 Copay Not Covered $50 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A
Mail Order Pharmacy
- Generic Formulary $20 Copay Not Covered $10 Copay Not Covered
- Brand Name Formulary $60 Copay Not Covered $60 Copay Not Covered
- Non-Formulary $100 Copay Not Covered $100 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

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