Page 11 - Sea Dwelling EE Guide 01-20

Option 5 Option 6 Option 7
Blue Shield Blue Shield Blue Shield
Gold Access+ Silver Full Gold Full
Plan Name 500/35 HMO 2300/45 PPO 500/30 PPO
Non- Non-
Network Name Access+ HMO Full PPO Network Full PPO Network
Plan Differences

Employee Premiums $ $$ $$$
Employee Cost Sharing Contribution, Contribution, Contribution,
Deductible, Copay, Deductible, Copay, Deductible, Copay,
Coinsurance Coinsurance Coinsurance
Network
- Network Size   
- In-Network Benefits ✓ ✓ ✓
- Non-Network Benefits ✓ ✓
Access to Providers Managed by Your Managed by You Managed by You
PCP
Health Benefits

Lifetime Max Benefit Unlimited Unlimited Unlimited
Deductible (Cal Year)
- Individual $500 $2,300 $4,600 $500 $1,000
- Family $1,000 $4,600 $9,200 $1,000 $2,000
Out-of-Pocket Maximum
- Individual $7,500 $7,800 $13,850 $7,800 $13,850
- Family $15,000 $15,600 $27,700 $15,600 $27,700
Coinsurance (Plan Pays) 80% 60% 50% 80% 60%
Office Visit Copay
- Preventive Care No Charge No Charge Not Covered No Charge Not Covered
- PCP $35 Copay $45 Copay Ded, 50% $30 Copay Ded, 40%
- Specialist $55 Copay $70 Copay Ded, 50% $50 Copay Ded, 40%
- Urgent Care $35 Copay $45 Copay Ded, 50% $30 Copay Ded, 40%
- Teladoc $5 Copay $5 Copay N/A $5 Copay N/A
Hospitalization
- Inpatient Ded, 20% Ded, 40% Ded, 50%* Ded, 20% Ded, 40%*
- Outpatient Surgery Ded, $150-$300 Ded, $250 Ded, 50%* Ded, $150 Ded, 40%*
Copay Copay, 40% Copay, 20%
Lab and X-Ray
- Diagnostic $35-$55 Copay See SBC Ded, 50%* See SBC Ded, 40%*
- Complex Ded, $50-$250 See SBC Ded, 50%* See SBC Ded, 40%*
Copay

Emergency Services Ded, $300 Copay Ded, $350 Copay, 40% Ded, $250 Copay, 20%
Chiropractic $15 Copay $15 Copay Ded, 50% $10 Copay Ded, 50%
Max 20 Visits/Year Max 20 Visits/Year Max 20 Visits/Year
*Limitations apply to non-network benefits. See SBC for details.