Page 7 - PLM Benefit Guide 4-2018 Final

Medical Benefits

Blue Shield Blue Shield
Silver Full PPO 2000/45 OffEx Platinum Full PPO 250/15 OffEx

Full PPO Network Non-Network* Full PPO Network Non-Network*

Health Benefits

Lifetime Maximum Benefit Unlimited Unlimited
Deductible (Annual)
 Individual $2,000 $4,000 $250 $500
 Family $4,000 $8,000 $500 $1,000
Coinsurance (You Pay) 40% 50% 10% 40%
Office Visit Copay
 Primary Care Physician $45 Copay Ded, 50% $15 Copay Ded, 40%
 Specialist Office Visit $60 Copay Ded, 50% $30 Copay Ded, 40%
Out-of-Pocket Maximum
 Individual $7,000 $10,000 $3,600 $8,000
 Family $14,000 $20,000 $7,200 $16,000

Hospitalization
 Inpatient Ded, 40% Ded, 50% Ded, 10% Ded, 40%
 Outpatient Ded, 40% Ded, 50% Ded, 10% Ded, 40%
Lab and X-Ray (Complex) Ded, 40% Ded, 50% Ded, 10% Ded, 40%
- Outpatient Hospital $100 Copay, Ded, 40% $100 Copay, Ded, 10%
Emergency Services $250 Copay, Ded, 40% $100 Copay, Ded, 10%
Urgent Care $45 Copay Ded, 50% $15 Copay Ded, 40%

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic Ded, 50% Ded, 50%
(12 Visits/Year) (12 Visits/Year)
Pharmacy Benefits
Pharmacy Deductible
 Individual None N/A None N/A
 Family None N/A None N/A

Retail Pharmacy
 Tier 1 $15 Copay Not Covered $5 Copay Not Covered
 Tier 2 $55 Copay Not Covered $30 Copay Not Covered
 Tier 3 $75 Copay Not Covered $50 Copay Not Covered
 Supply Limit 30 Days N/A 30 Days N/A
Mail Order Pharmacy
 Tier 1 $30 Copay Not Covered $10 Copay Not Covered
 Tier 2 $110 Copay Not Covered $60 Copay Not Covered
 Tier 3 $150 Copay Not Covered $100 Copay Not Covered
 Supply Limit 90 Days N/A 90 Days N/A
*Non-Network benefits are based off of the plan’s non-network reimbursement schedule, and various benefits have limitations

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