Page 6 - Advertise Purple Benefit Guide

Medical Insurance

Blue shield Blue Shield
Plan Name HMO PPO
Network Name Gold Access HMO 1500/35 Silver Full PPO 1800/55 Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $1,500 $1,800 $3,400
- Family $3,000 $3,600 $6,800
Out-of-Pocket Maximum
- Individual $7,800 $7,800 $13,850
- Family $15, 600 $15,600 $27, 700

Co-Insurance (Plan Pays) 80% 65% 50%
Office Visit Copay
- Preventive Care No Charge No Charge Not Covered
- Primary Care Physician $35 Copay $55 Copay Deductible, 50%
- Specialist Office Visit $60 Copay $80 Copay Deductible, 50%
- Urgent Care $35 Copay $55 Copay Deductible, 50%
- Telemedicine $5 Copay $5 Copay N/A
Hospitalization
- Inpatient Ded, 20% Deductible, 35% Deductible, 50%*
- Outpatient Ded, $150 Copay/Surgery Deductible, 35% Deductible 50%*
Ded, $300 Copay/Surgery Ded, $250 Copay 35% Deductible 50%*

Lab and X-Ray
- Diagnostic $40—$60 Copay See SBC Deductible, 50%
- Complex $60- $250 Copay See SBC Deductible, 50%

Emergency Services Ded, $300 Copay Deductible, $300 Copay, 35%
Chiropractic $15 Copay $15 Copay Deductible, 50%
20 Visits/Calendar Year 20 Visits/ Calendar Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $100 $300 Not Covered
- Family $200 $600 Not Covered
Retail Pharmacy
- Generic Formulary $15 Copay $20 Copay Not Covered
- Brand Name Formulary $35 Copay $75 Copay Not Covered
- Non-Formulary $55 Copay $115 Copay Not Covered
- Supply Limit 20% Max $250 30% Max $250 Not Covered
30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay $40 Copay Not Covered
- Brand Name Formulary $70 Copay $150 Copay Not Covered
- Non-Formulary $110 Copay $230 Copay Not Covered
- Supply Limit 20% Max $500 30% Max $500 Not Covered
90 Days 90 Days N/A
* Limitations apply to non network benefits. See SBC for detail

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