Page 10 - Surfline Benefits Guide 2017

Medical

Blue Shield Blue Shield
Gold PPO Platinum PPO
Network PPO Non-Network PPO Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $250 $500 $150 $300
• Family $500 $1,000 $300 $600
• Individual Protection* Yes Yes Yes Yes
Physician Office Visit
• PCP $30 Copay Deductible, 40% $15 Copay Deductible, 40%
• Specialist $50 Copay Deductible, 40% $30 Copay Deductible, 40%
Out-of-Pocket Maximum
• Individual $6,800 $10,000 $3,000 $8,000
• Family $13,600 $20,000 $6,000 $16,000
Hospitalization
• Inpatient Deductible, 20% Deductible, 40% Deductible, 10% Deductible, 40%
Max $2,000 Benefit/Day Max $2,000 Benefit/Day
• Outpatient Surgery Deductible, 20% Deductible, 40% Deductible, 10% Deductible, 40%
Max $350 Benefit/Day Max $350 Benefit/Day
Lab and X-Ray
• Diagnostic Deductible, 20% Deductible, 40% Deductible, 10% Deductible, 40%
• Complex (Hospital) Deductible, $100 Deductible, 40% Deductible, $100 Deductible, 40%
Copay, 20% Copay, 10%
• Complex (Non-Hospital) Deductible, 20% Deductible, 40% Deductible, 10% Deductible, 40%
Emergency Services Deductible, $200 Copay, 20% Deductible, $100 Copay, 10%
Urgent Care $30 Copay Not Covered $15 Copay Not Covered
Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic 50% 50% 50% 50%
12 Visits/Year 12 Visits/Year
PHARMACY BENEFITS
Pharmacy Deductible None None
Retail Pharmacy
• Tier 1 Ded, $15 Copay Not Covered $5 Copay Not Covered
• Tier 2 Ded, $40 Copay Not Covered $30 Copay Not Covered
• Tier 3 Ded, $60 Copay Not Covered $50 Copay Not Covered
• Tier 4 30% Max $250 Not Covered 30% Max $250 Not Covered
• Supply Limit 30 Days N/A 30 Days N/A
Mail Order Pharmacy 2x Retail Not Covered 2x Retail Not Covered
• Supply Limit 90 Days N/A 90 Days N/A
*Individual Protection: for members within a family, the individual deductible will still apply.

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