Page 6 - Rehab Alliance EE Guide 08-20 (TRIO)

BENEFITS

Medical Insurance

Options 1 & 2 Option 3 Option 4
Blue Shield Blue Shield Blue Shield
Plan Name Gold HMO Platinum HMO Gold PPO
Network Name Access+ & Trio HMO Access+ HMO Full PPO Non-Network
Health Benefits

Deductible (Annual)
- Individual $1,500 None $750 $1,500
- Family $3,000 None $1,500 $3,000
Out-of-Pocket Maximum
- Individual $7,800 $2,350 $7,800 $13,850
- Family $15,600 $4,700 $15,600 $27,700

Co-Insurance (Plan Pays) 80% 100% 80% 60%
Office Visit Copay
- Preventive Care No Charge No Charge No Charge Not Covered
- Primary Care Physician $35 Copay $25 Copay $30 Copay Deductible, 40%
- Specialist Office Visit $60 Copay $50 Copay $50 Copay Deductible, 40%
- Urgent Care $35 Copay $25 Copay $30 Copay Deductible, 40%
Hospitalization
- Inpatient Deductible, 20% $250/Day Max 3 Copays Deductible, 20% Deductible, 40%*
- Outpatient (Center) Ded, $150 Copay $100 Copay Deductible, 20% Deductible, 40%*
- Outpatient (Hospital) Ded, $300 Copay $150 Copay Ded, $150 Copay, 20% Deductible, 40%*
Lab and X-Ray (Center)
- Diagnostic Lab $40 copay / X-Ray $60 copay Lab $20 Copay / X-Ray $50 Copay Lab: $30 / X-Ray $50 Copay Deductible, 40%*
- Complex Imaging $50 Copay $50 Copay Deductible, 20% Deductible, 40%*
Lab and X-Ray (Hospital)
- Diagnostic Lab/$40 copay / X-Ray/$60 copay Lab $20 Copay / X-Ray $50 Copay Lab Ded, 20% / X-Ray $100 Copay Deductible, 40%*
- Complex Imaging Ded, $250 Copay $200 Copay $100, Ded, 20% Deductible, 40%*
Emergency Services Deductible, $300 Copay $250 Copay Deductible, $250 Copay, 20%
Chiropractic $15 Copay $15 Copay $10 Copay Deductible, 50%
20 Visits/Year 20 Visits/Year 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $100 None $250 N/A
- Family $200 None $500 N/A
Retail Pharmacy
- Tier 1 $15-$20 Copay $5 Copay $10 Copay Not Covered
- Tier 2 Ded, $35-$55 Copay $15 Copay Ded, $40 Copay Not Covered
- Tier 3 Ded, $55-$85 Copay $25 Copay Ded, $70 Copay Not Covered
- Tier 4 Ded, 20% Max $250 20% Max $250 Ded, 30% Max $250 Not Covered
- Supply Limit 30 Days 30 Days 30 Days N/A
Mail Order Pharmacy
- Tier 1 $30 Copay $10 Copay $20 Copay Not Covered
- Tier 2 Ded, $70 Copay $30 Copay Ded, $80 Copay Not Covered
- Tier 3 Ded, $110 Copay $50 Copay Ded, $140 Copay Not Covered
- Tier 4 Ded, 20% Max $500 20% Max $500 Ded, 30% Max $500 Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
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*Limitations apply. See SBC for details.