Page 8 - FSSI EE Guide 07-20 - OOS

Blue Shield Blue Shield
Plan Name PPO HSA PPO
Network Name PPO Non-Network PPO Non-Network
Plan Differences
Employee Premiums $$$ $$

Health Savings Account ✓
Employee Cost Sharing Contribution, Deductible, Contribution, Deductible,
Copay, Coinsurance Copay, Coinsurance

Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits ✓ ✓
Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual $500 $1,800
- Individual in Family $500 $2,800
- Family $1,500 $3,600
Out-of-Pocket Maximum
- Individual $4,000 $8,000 $4,500 $8,000
- Individual in Family $4,000 $8,000 $4,500 $8,000
- Family $8,000 $16,000 $9,000 $16,000
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Specialist $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Urgent Care $30 Copay Deductible, 40% Deductible, 20% Deductible, 40%
- Teladoc $5 Copay N/A $5 Copay N/A
Hospitalization
- Inpatient Deductible, 10% Deductible, 40%* Deductible, 20% Deductible, 40%*
- Outpatient Surgery Deductible, 5%-15% Deductible, 40%* Deductible, 10%-20% Deductible, 40%*
Lab and X-Ray Deductible,
- Diagnostic $30-$55 Copay Deductible, 40%* Deductible, 20%- Deductible, 40%*
30%
- Complex Deductible, 10%- Deductible, 40%* Deductible, Deductible, 40%*
20% $100 Copay, 20%
Emergency Services $150 Copay, 10% Deductible, $150 Copay, 20%

Chiropractic $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
Max 20 Visits/Year Max 20 Visits/Year

Acupuncture $25 Copay Deductible, 40% Deductible, 20% Deductible, 40%
Max 20 Visits/Year Max 20 Visits/Year

*Limitations apply. See SBC for details.