Page 9 - Rauxa EE Guide 04-18 CA

Medical Insurance

Blue Shield Blue Shield
PPO Low PPO High
Network Name PPO Non-Network PPO Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Calendar Year Deductible
• Individual $750 $1,500 $250
• Family (Ind Protection*) $1,500 ($750) $3,000 ($1,500) $500 ($250)
Coinsurance (Plan Pays) 80% 60% 90% 70%
Physician Office Visit
• PCP $25 Copay Deductible, 40% $10 Copay Deductible, 30%
• Specialist $25 Copay Deductible, 40% $10 Copay Deductible, 30%
• Access+ Specialist N/A N/A N/A N/A
Out-of-Pocket Maximum
• Individual $4,750 $9,500 $1,250 $3,250
• Family (Ind Protection*) $9,500 ($4,750) $19,000 ($9,500) $2,500 ($1,250) $6,500 ($3,250)
Hospitalization
• Inpatient Deductible, Deductible, 40%** Deductible, 10% Deductible, 30%**
$100 Copay, 20%
• Outpatient Surgery Deductible, 20% Deductible, 40%** Deductible, 10% Deductible, 30%**
Emergency Services $100 Copay, 20% $100 Copay, 10%
Urgent Care $25 Copay Deductible, 40% $10 Copay Deductible, 30%
Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic $25 Copay Deductible, 40% $25 Copay Deductible, 30%
12 Visits/Year 12 Visits/Year
PHARMACY BENEFITS
Annual Deductible None None
Retail Pharmacy
• Tier 1 $10 Copay $10 Copay + 25% $10 Copay $10 Copay + 25%
• Tier 2 $30 Copay $30 Copay + 25% $30 Copay $30 Copay + 25%
• Tier 3 $50 Copay $50 Copay + 25% $50 Copay $50 Copay + 25%
• Tier 4 30% Max $200 See SBC 30% Max $200 See SBC
• Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
• Tier 1 $20 Copay Not Covered $20 Copay Not Covered
• Tier 2 $60 Copay Not Covered $60 Copay Not Covered
• Tier 3 $100 Copay Not Covered $100 Copay Not Covered
• Tier 4 30% Max $400 Not Covered 30% Max $400 Not Covered
• Supply Limit 90 Days N/A 90 Days N/A

*Individual Protection limits family liability for healthcare costs by capping individual family member’s deductibles and out-of-pocket
maximums. As soon as one family member reaches the individual deductible limit, the plan begins to make payments for that family
member. Any portion of the family deductible that is left over will be applied to services obtained from the remaining family members
for the calendar year. Additionally, with an out-of-pocket maximum that includes individual protection, the plan will pay 100% of
covered expenses for any family member who reaches the individual out-of-pocket maximum limit. Any portion of the family out-
of-pocket maximum that is left over will be applied to services obtained from the remaining family members for the calendar year.
**Limitations apply. See SBC for details.
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