Page 9 - Surfline Benefits Guide 2017

Medical

Blue Shield Blue Shield
Platinum HMO Silver PPO HSA
Network Access+ HMO PPO HSA Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual None $2,000 $4,000
• Family None $4,000 $8,000
• Individual Protection* N/A Yes ($2,600) Yes
Physician Office Visit
• PCP $20 Copay Deductible, 20% Deductible, 50%
• Specialist $40 Copay Referred / Self-Referred Deductible, 20% Deductible, 50%
Out-of-Pocket Maximum
• Individual $1,750 $5,050 $10,000
• Family $3,500 $6,500 $20,000
Hospitalization
• Inpatient $500 Copay Deductible, 20% Deductible, 50%
Max $2,000 Benefit/Day
• Outpatient Surgery $100-$150 Copay Deductible, 20% Deductible, 50%
Max $350 Benefit/Day
Lab and X-Ray
• Diagnostic $10-$30 Copay Deductible, 20% Deductible, 50%
• Complex (Hospital) Deductible, $100 Copay Deductible, $100 Copay, Deductible, 50%
20%
• Complex (Non-Hospital) Decuctible, $30 Copay Deductible, 20% Deductible, 50%
Emergency Services $200 Copay Deductible, $150 Copay, 20%
Urgent Care $20 Copay Deductible, 20% Not Covered
Preventive Care No Charge No Charge Not Covered
Chiropractic $15 Copay Not Covered Not Covered
15 Visits/Year
PHARMACY BENEFITS
Pharmacy Deductible None Health Deductible Applies
Retail Pharmacy
• Tier 1 $5 Copay Deductible, $15 Copay Not Covered
• Tier 2 $15 Copay Deductible, $50 Copay Not Covered
• Tier 3 $25 Copay Deductible, $75 Copay Not Covered
• Tier 4 20% Max $250 30% Max $250 Not Covered
• Supply Limit 30 Days 30 Days N/A
Mail Order Pharmacy 2x Retail 2x Retail Not Covered
• Supply Limit 90 Days 90 Days N/A
*Individual Protection: for members within a family, the individual deductible will still apply.

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