Page 9 - Moonwell Studios Benefit Guide

Medical Plan Highlights

Blue Shield Kaiser
Plan Name Platinum HMO Platinum HMO

Network Name HMO Access+ Network Kaiser
Plan Differences
Employee Premiums $$ $$
Health Savings Account
- Moonwell Studios Funded
- Employee Funded
Employee Cost Sharing Contribution, Copay Contribution, Copay

Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits

Access to Providers Managed by Your PCP Managed by Kaiser
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual None None
- Family None None

Out-of-Pocket Maximum
- Individual $1,900 $3,000
- Family $3,800 $6,000
Coinsurance (You Pay) N/A N/A

Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $20 Copay $10 Copay
- Specialist $40 Copay $20 Copay
- Urgent Care $20 Copay $10 Copay
- Virtual Visit $5 Copay No Charge

Hospitalization
- Inpatient $500 Copay $500 Copay
- Outpatient Surgery $100 - $150 Copay $300 Copay

Lab and X-Ray
- Diagnostic $10 - $30 Copay $20 - $40 Copay
- Complex $30 - $100 Copay $150 Copay

Emergency Services $200 Copay $200 Copay

Chiropractic $15 Copay $15 Copay
Max 20 Visits/Year Max 20 Visits/Year

Employee Benefits 9