Page 8 - Premier EE Guide 01-20 - CA- Updated 01.03.2020

BENEFITS

MEDICAL INSURANCE

Blue Shield
Plan Name Full PPO Savings Two-Tier
Embedded Deductible
(HDHP PPO Medical)

Network Name Full PPO Non-Network
Health Benefits

Deductible (Annual)
- Individual $1,500
- Family $2,800/Ind; $3,000/family
Co-Insurance (Plan Pays) 90% 60%
Office Visit Copay
- Primary Care Physician Deductible, 10% Deductible, 40%
- Specialist Office Visit Deductible, 10% Deductible, 40%

Out-of-Pocket Maximum
- Individual $3,500 $6,000
- Family $7,000 $12,000
Hospitalization
- Inpatient Deductible, 10% Deductible, 40% up to $600/day

Ded., 15% Hosp. Deductible, 40% up to $350/ day
- Outpatient Surgery Ded., 5% Ambulatory Surgery Center

Lab and X-Ray
Deductible, 10% Deductible, 40%

Emergency Services Deductible, $150/ visit plus 10%
Urgent Care Deductible, 10% Deductible, 40%

Preventive Care $0 Copay Not Covered
Physical, Occupational, Respiratory Deductible, 10% Deductible, 40%
and Speech Therapy
Pharmacy Benefits Health Deductible Applies Health Deductible Applies

Retail Pharmacy (Up to 30 Days)
Tier 1 drugs $10 Copay $10 Copay + 25%
Tier 2 drugs $25 Copay $25 Copay + 25%
Tier 3 drugs $40 Copay $40 Copay + 25%
Tier 4 drugs 30% up to $200/Rx 30% + 25% up to $200/Rx

Mail Order Pharmacy (Up to 90 Days)
Tier 1 drugs $20 Copay Not Covered
Tier 2 drugs $50 Copay Not Covered
Tier 3 drugs $80 Copay Not Covered
Tier 4 drugs (Specialty 30 Days) 30% up to $400/Rx Not Covered
*Limitations apply. See SBC for details.

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