Page 7 - Electric Ben Guide 08-18

MEDICAL

BLUE SHIELD BLUE SHIELD BLUE SHIELD
PLAN FEATURES PLATINUM HMO SILVER FULL HSA PLATINUM FULL PPO
Trio ACO or PPO Network Non-Network PPO Network Non-Network
Access+ Full
Annual Deductible
Individual $0 $2,000 $4,000 $0 $0
Family $0 $4,000 $8,000 $0 $0
Individual Protection* N/A Yes ($2,700) Yes N/A N/A
Physician Office Visit
Preventive Care No Cost No Cost Not Covered No Cost Not Covered
PCP $20 Copay 20% 50% $10 Copay 40%
Specialist $40 Copay 20% 50% $25 Copay 40%
Urgent Care $20 Copay 20% 50% $10 Copay 40%
Out-of-Pocket Maximum
Individual $1,350 $5,550 $10,000 $3,300 $5,000
Family $2,700 $6,500 $20,000 $6,600 $10,000
Hospitalization $500 Copay 20% 50% Max $2,000 10% 40% Max $2,000
Outpatient Surgery $100-$150 Copay 20% 50% Max $350 10% 40% Max $350
Lab and X-Ray $10-$30 Copay 20% 50% 10% 40%
Complex $100 Copay $100 Copay, 20% 50% Max $350 $100 Copay, 10% 40% Max $350
Emergency Services $200 Copay $150 Copay, 20% $100 Copay, 10%
Prescription Drugs
Retail - 30 Days Ded, then:
- Tier 1 $5 Copay $15 Copay Not Covered $5 Copay Not Covered
- Tier 2 $15 Copay $50 Copay Not Covered $30 Copay Not Covered
- Tier 3 $25 Copay $75 Copay Not Covered $50 Copay Not Covered
- Tier 4 20% Max $250 30% Max $250 Not Covered 30% Max $250 Not Covered
Mail Order - 90 Days Ded then:
- Tier 1 $10 Copay $30 Copay Not Covered $10 Copay Not Covered
- Tier 2 $30 Copay $100 Copay Not Covered $60 Copay Not Covered
- Tier 3 $50 Copay $150 Copay Not Covered $100 Copay Not Covered
- Tier 4 20% Max $500 30% Max $500 Not Covered 30% Max $500 Not Covered
*Individual Protection: for members within a family, the individual deductible will still apply.

H FINDING A MEDICAL PROVIDER:

Visit the websites listed below or call (888) 256-1915.
• Trio ACO Network HMO - Go to www.blueshieldca.com/networktriohmo
• Full Network HMO - Go to www.blueshieldca.com/networkhmo
• HSA - Go to www.blueshieldca.com/networkppo
• PPO - Go to www.blueshieldca.com/networkppo

7