Page 9 - 2019 Blacoh Benefit Guide Final 11/13/18

Medical Benefits

Plan Features Blue Shield PPO

Gold Full PPO 250/30

Network In-Network PPO Non-Network Providers
Deductible (Annual)
- Individual $450 $500
- Family $900 (embedded) $1,000 (embedded)

Physician Services
- Office Visits $30 / $50 (deductible waived) 40% after deductible
- Preventive Care No Charge Not covered
- Teledoc Consultation $5 per consultation Not covered
(deductible waived)
- Diagnostic Lab/X-Ray Free Standing: 20% after deductible 40% after deductible
- Imaging Hospital: $100 per visit + 20% 40% after deductible
after deductible 40% after deductible

- Rehab (Visit limits apply) 20% after deductible 40% after deductible
- Chiropractic Care (Visit limits apply) 50% (deductible waived) 50% (deductible waived)

Out of Pocket Maximum $7,000 (includes deductible) $10,000 (includes deductible)
- Individual $14,000 (embedded, $20,000 (embedded,
- Family
includes deductible) includes deductible)
Hospitalization
- Inpatient 20% after deductible 40% after deductible
- Outpatient 20% after deductible 40% after deductible

Mental Health & Substance Abuse
- In-Patient 20% after deductible 40% after deductible
- Out-Patient 20% after deductible 40% after deductible
Emergency Services
- Emergency Room $200 + 20% after deductible $200 + 20% after deductible
- Ambulance Transport 20% after deductible 20% after deductible
- Urgent Care $30 (deductible waived) Not covered
Maternity
- Prenatal Care No charge on first visit, 40% after deductible
20% after deductible
- Postnatal Care No charge on first visit, 40% after deductible
20% after deductible
- Inpatient Delivery 20% after deductible 40% after deductible
Prescription Drugs
- Tier 1: Generic $15 Copay Not covered
- Tier 2: Preferred Brand $40 Copay Not covered
- Tier 3: Non-Preferred Brand $60 Copay Not covered
- Tier 4: Specialty 30% up to $250 Not covered
Supply Limit 30 Days N/A
Mail Order Pharmacy 2 times retail Not covered
Mail Order Supply Limit Up to 90 Days Not covered

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