Page 6 - PLM Benefit Guide 4-2018 - Non-CA Final

Medical Benefits

Blue Shield
Silver Full PPO 2000/45 OffEx

Full PPO Network Non-Network*

Health Benefits

Lifetime Maximum Benefit Unlimited

Deductible (Annual)
 Individual $2,000 $4,000
 Family $4,000 $8,000
Coinsurance (You Pay) 40% 50%
Office Visit Copay
 Primary Care Physician $45 Copay Ded, 50%
 Specialist Office Visit $60 Copay Ded, 50%
Out-of-Pocket Maximum
 Individual $7,000 $10,000
 Family $14,000 $20,000

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

Urgent Care $45 Copay Ded, 50%
Preventive Care No Charge Not Covered
Chiropractic Ded, 50%
(12 Visits/Year)
Pharmacy Benefits
Pharmacy Deductible
 Individual None N/A
 Family None N/A
Retail Pharmacy
 Tier 1 $15 Copay Not Covered
 Tier 2 $55 Copay Not Covered
 Tier 3 $75 Copay Not Covered
 Supply Limit 30 Days N/A

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

6