Page 7 - PLM Benefit Guide 4-2018 - Non-CA Final

Medical Benefits

Blue Shield
Platinum Full PPO 250/15 OffEx

Full PPO Network Non-Network*

Health Benefits

Lifetime Maximum Benefit Unlimited

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

Hospitalization
 Inpatient Ded, 10% Ded, 40%
 Outpatient Ded, 10% Ded, 40%
Lab and X-Ray (Complex) Ded, 10% Ded, 40%
- Outpatient Hospital $100 Copay, Ded, 10%
Emergency Services $100 Copay, Ded, 10%

Urgent Care $15 Copay Ded, 40%
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 $5 Copay Not Covered
 Tier 2 $30 Copay Not Covered
 Tier 3 $50 Copay Not Covered
 Supply Limit 30 Days N/A

Mail Order Pharmacy
 Tier 1 $10 Copay Not Covered
 Tier 2 $60 Copay Not Covered
 Tier 3 $100 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

7