Page 5 - BB Dakota Benefit Summary 12-2017.pub

Benefits

Medical Insurance

Blue Shield Blue Shield
HMO PPO

Plan Name Pla num Access+ HMO Pla num Full
0/25 OffEx PPO 150/15 OffEx
Network Access+ Full PPO Non‐Network
Life me Maximum Unlimited Unlimited

Deduc ble (Annual)
‐ Individual None $150 $300
‐ Family* None $300 $600
Co‐Insurance (You Pay) N/A 10% 40%

Office Visit Copay
‐ Primary Care Physician $25 Copay $15 Copay Deduc ble, 40%
‐ Specialist $50 Copay $30 Copay Deduc ble, 40%
Out‐of‐Pocket Maximum Includes Deduc ble Includes Deduc ble
‐ Individual $2,500 $3,000 $8,000
‐ Family* $5,000 $6,000 $16,000

Hospitaliza on
‐ Inpa ent $250/Day Deduc ble, 10% Deduc ble, 40% to
(3 Copays Max) $2,000/Day
‐ Outpa ent $100‐$150 Copay Deduc ble, 10% Deduc ble, 40% to
$350/Day
Lab and X‐Ray $20 Copay / $50 Copay Deduc ble, 10% Deduc ble, 40%
‐ Complex $200 Copay
Emergency Services $250 Copay $100 Copay, 10%

Urgent Care $25 Copay $15 Copay Not Covered
Preven ve Care No Charge Deduc ble Waived, Not Covered
No Charge
Pharmacy Benefits

Pharmacy Deduc ble None None
Retail Pharmacy
‐ Tier 1 $5 Copay $5 Copay Not Covered
‐ Tier 2 $15 Copay $30 Copay Not Covered
‐ Tier 3 $25 Copay $50 Copay Not Covered
‐ Retail Supply Limit 30 Days 30 Days N/A

Mail Order Pharmacy
‐ Tier 1 $10 Copay $10 Copay Not Covered
‐ Tier 2 $30 Copay $60 Copay Not Covered
‐ Tier 3 $50 Copay $100 Copay Not Covered
‐ Supply Limit 90 Days 90 Days N/A

*For family coverage, there is an individual out‐of‐pocket maximum within the family out‐of‐pocket maximum, and an individual
medical deduc ble within the family medical deduc ble

5