Page 5 - Brixton EE Benefits Guide 12-18

Benefits

Medical Insurance

Blue Shield Blue Shield
Silver Full PPO 1700/40 Platinum Full PPO 0/10

PPO Full Non-Network* PPO Full Non-Network*
Network Name
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual / Family $1,700 / $3,400 $3,400 / $6,800 None None

Co-Insurance (You Pay) 35% 50% 10% 40%
Office Visit Copay
- Primary Care Physician $55 Copay Ded, 50% $10 Copay 40%
- Specialist Office Visit $70 Copay Ded, 50% $25 Copay 40%
Out-of-Pocket Maximum
- Individual / Family $7,000 / $14,000 $10,000 / $20,000 $3,300 / $6,600 $5,000 / $10,000
Hospitalization
- Inpatient Ded, 35% Ded, 50% 10% 40%
- Outpatient Ded, 35% Ded, 50% 10% 40%

Lab and X-Ray Ded, 35% Ded, 50% 10% 40%
- Advanced $100, Ded, 35% Ded, 50% $100, 10% 40%
Emergency Services $250 Copay, Ded, 35% $100 Copay, 10%

Urgent Care $55 Copay Ded, 50% $10 Copay 50%
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 (Ind / Fam) $300 / $600 N/A None None
Retail Pharmacy (30 Day Supply) No Ded on Tier 1
- Tier 1 $15 Copay Not Covered $5 Copay Not Covered
- Tier 2 $50 Copay Not Covered $30 Copay Not Covered
- Tier 3 $75 Copay Not Covered $50 Copay Not Covered
Mail Order Pharmacy (90 Day Supply) No Ded on Tier 1
- Tier 1 $30 Copay Not Covered $10 Copay Not Covered
- Tier 2 $100 Copay Not Covered $60 Copay Not Covered
- Tier 3 $150 Copay Not Covered $100 Copay Not Covered
*Benefit limits may apply

Finding a PPO Medical Provider
Blue Shield PPO participants should go to blueshieldca.com/networkppo.

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