Page 7 - Evisions Benefit Guide 2020 - Effective 1.1.2020

Benefits

Medical Insurance - Available to California & Non California Employees

Blue Shield Blue Shield
Plan Name PPO HDHP/HSA
Network Name Full PPO Non-Network Full PPO Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $1,000 $3,000 $4,400
- Family Member $1,000 $3,000 $4,400
- Family $3,000 $9,000 $8,800
Co-Insurance (Plan Pays) 80% 60% 100% 50%
Office Visit Copay
- Primary Care Physician $35 Copay Deductible, 40% Deductible, 0% Deductible, 50%
- Specialist Office Visit $35 Copay Deductible, 40% Deductible, 0% Deductible, 50%
Out-of-Pocket Maximum
- Individual $5,500 $10,000 $4,400 $10,000
- Family Member $5,500 $10,000 $4,400 $10,000
- Family $11,000 $20,000 $8,800 $20,000

Hospitalization
- Inpatient Deductible, 20% Deductible, 40%* Deductible, 0% Deductible, 50%*

- Outpatient Deductible, 10%-25% Deductible, 40%* Deductible, 0% Deductible, 50%*

Emergency Services Deductible, $150 Copay, 20% Deductible, 0%
Urgent Care $35 Copay Deductible, 40% Deductible, 0% Deductible, 50%
Preventive Care 100% Not Covered 100% Not Covered
Chiropractic Deductible, $25 Copay Deductible, 40% Deductible, 0% Deductible, 50%

20 Visits/Year 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 Medical Plan Medical Plan
- Family $0 $0 Deductible Applies Deductible Applies

Retail Pharmacy
- Tier 1 $15 Copay $15 + 25% Copay Deductible, 0% Deductible, 0%
- Tier 2 $30 Copay $30 + 25% Copay Deductible, 0% Deductible, 0%
- Tier 3 $45 Copay $45 + 25% Copay Deductible, 0% Deductible, 0%
- Tier 4 30% Max $200 Copay 30% Max $200 Copay+ 25% Deductible, 0% Deductible, 0%
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $30 Copay Not Covered Deductible, 0% Not Covered
- Tier 2 $60 Copay Not Covered Deductible, 0% Not Covered
- Tier 3 $90 Copay Not Covered Deductible, 0% Not Covered
- Tier 4 30% Max $400 Copay Not Covered Deductible, 0% Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
*Limitations apply. See SBC for details.
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