Page 8 - Sumitomo EE Guide 06-18.pub

BENEFITS

MEDICAL INSURANCE

California Residents Only California and Non-California Residents
BLUE SHIELD BLUE SHIELD
PLAN NAME HMO PPO
Network Network Network Non‐Network
Health Benefits

Life me Maximum Benefit Unlimited Unlimited
Calendar Year Deduc ble
‐ Individual $0 $250
‐ Family $0 $500
Office Visit Copay
‐ Preven ve Care No Charge No Charge Not Covered
‐ Primary Care Physician $20 Copay $15 Copay Deduc ble, 30%
‐ Specialist Office Visit $20 Copay; Access+ $35 Copay $15 Copay Deduc ble, 30%
‐ Urgent Care $20 Copay $15 Copay Deduc ble, 30%
‐ Teladoc $5 Copay $5 Copay Not Covered
Calendar Year Out‐of‐Pocket Maximum
‐ Individual $1,000 $2,250 $10,250
‐ Family $2,000 $4,500 $20,500

Hospitaliza on
‐ Inpa ent No Charge Deduc ble, 10% Deduc ble, 30%*
‐ Outpa ent No Charge Deduc ble, 10% Deduc ble, 30%*
Lab and X‐Ray
‐ Diagnos c No Charge Deduc ble, $15‐$40 Copay Deduc ble, 30%
‐ Radiological and Nuclear Imaging No Charge Deduc ble, 10% Deduc ble, 30%*
Emergency Services $100 Copay $100 Copay, 10%

Durable Medical Equipment 50% Deduc ble, 10% Deduc ble, 30%
Chiroprac c and Acupuncture $10 Copay Deduc ble, $25 Copay Deduc ble, 30%
30 Visits/Year Chiro: 12 Visits/Year; Acupuncture: 20 Visits/Year
Pharmacy Benefits

Retail Prescrip ons
‐ Contracep ve Drugs and Devices No Charge No Charge Applicable Tier Copay
‐ Tier 1 $10 Copay $10 Copay 25% + $10 Copay
‐ Tier 2 $25 Copay $30 Copay 25% + $30 Copay
‐ Tier 3 $40 Copay $50 Copay 25% + $50 Copay
‐ Tier 4 20%, Max $200 Copay 30%, Max $200 Copay 25% + 30%, Max $200
‐ Supply Limit Up to 30 Days Up to 30 Days Up to 30 Days
Mail Service Prescrip ons
‐ Contracep ve Drugs and Devices No Charge No Charge Not Covered
‐ Tier 1 $20 Copay $20 Copay Not Covered
‐ Tier 2 $50 Copay $60 Copay Not Covered
‐ Tier 3 $80 Copay $100 Copay Not Covered
‐ Tier 4 (excluding specialty drugs) 20%, Max $400 Copay 30%, Max $400 Copay Not Covered
‐ Supply Limit Up to 90 Days Up to 90 Days N/A

*Limita ons apply. See SBC for details.

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