Blue Shield
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Blue Shield PPO 90/70
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Blue Shield HMO
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Blue Shield PPO/HRA
|
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| Life and AD&D Insurance |
$10,000 for all Active Employees
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| Medical Lifetime Benefit Maximum |
None
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None
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None
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Blue Shield PPO 90/70
|
Blue Shield HMO
|
Blue Shield PPO/HRA
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|
Network
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Out of Network
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Network Only
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Network
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Out of Network
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| Calendar Year Deductible |
$100/Person
$200/Family
|
$250/Person
$500/Family
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None
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$1,700/Person
$3,400/Family Member
$3,400/Family
|
|
| Calendar Year Copayment Maximum |
$1,000/Person
$2,000/Family
|
$3,000/Person
$6,000/Family
|
$1,000/Person
$2,000/Family
|
$4,500/Person
$6,550/Family Member
|
$4,500/Person
$6,550/Family Member
|
| For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. | For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. | ||||
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MEMBER COPAYMENTS
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|---|---|---|---|---|---|
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Blue Shield PPO 90/70
|
Blue Shield HMO
|
Blue Shield PPO/HRA
|
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|
Network
|
Out of Network
|
Network Only
|
Network
|
Out of Network
|
|
| Physician Services |
10%
|
30%
|
$15 per visit
|
20%
|
40%
|
| Lab, X-rays, Diagnostics |
10%
|
30%
|
no charge
|
20%
|
40%
|
| Hospitalization Services |
10%
|
30% of up to $600/day + 100% of additional charges
|
no charge
|
20%
|
40% of up to $600/day + 100% of additional charges
|
| Emergency Health Coverage (Copay is waived if admitted as inpatient) |
10%
|
10%
|
$50
|
$100+20%
|
$100+20%
|
| Durable Medical Equipment |
10%
|
30%
|
20%
|
20%
|
40%
|
|
MENTAL HEALTH SERVICES (PSYCHIATRIC)
|
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|
Blue Shield PPO 90/70
|
Blue Shield HMO
|
Blue Shield PPO/HRA
|
|||
|
Network
|
Out of Network
|
Network Only
|
Network
|
Out of Network
|
|
| Inpatient |
10%
|
30%
Hospital Services and Residential Care: 30% coinsurance of up to $600/day plus 100% of additional charges
|
no charge
|
20%
|
40%
Hospital Services and Residential Care: 40% of up to $600/day plus 100% of additional charges
|
| Outpatient |
10%
|
30%
30% Partial Hospitalization: 30% coinsurance of up to $350/day plus 100% of additional charges
|
$15 per office visit,
No charge for other services
|
20%
|
40%
Hospital Services and Residential Care: 40% of up to $600/day plus 100% of additional charges
|
|
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)
|
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|
Blue Shield PPO 90/70
|
Blue Shield HMO
|
Blue Shield PPO/HRA
|
|||
|
Network
|
Out of Network
|
Network Only
|
Network
|
Out of Network
|
|
| Inpatient |
10%
|
30% up to $600/day + 100% additional charges
|
no charge
|
20%
|
40% up to $600/day + 100% additional charges
|
| Outpatient visits |
10%
|
30% office visit & psych testing
30% up to $350/day + 100% additional charges
|
$15 per office visit,
No charge for other services
|
20%
|
40% office visit & psych testing
Other services: 40% up to $350/day + 100% additional charges
|
|
PRESCRIPTION DRUG COVERAGE
|
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|
Blue Shield PPO 90/70
|
Blue Shield HMO
|
Blue Shield PPO/HRA
|
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|
Network
|
Outside
|
Network Only
|
Network
|
Outside
|
|
| Generic |
$5 network
$10 mail service
|
25% of billed + $5 copay
Mail not covered
|
$10 network
$20 mail service
|
$10 network
$20 mail service
|
25% of allowable amount plus co-pay of $10
Mail not covered
|
| Brand Name |
$10 network
$20 mail service
|
25% of billed + $10 copay
Mail not covered
|
$20 network
$40 mail service
|
$25 network
$50 mail service
|
25% of allowable amount plus co-pay of $25
Mail not covered
|
| Non-Formulary Brand Name |
$25 network
$50 mail service
|
25% of billed + $25 copay
Mail not covered
|
$35 network
$70 mail service
|
$40 network
$80 mail service
|
25% of allowable amount plus co-pay of $40
Mail not covered
|
| Specialty Medications |
30% up to $200 copay per prescription
|
30% up to $200 copay per prescription + 25% of purchase price Mail not covered |
20% up to $200 copay per prescription
20% up to $400 mail service
|
30% up to $200 copay per prescription
30% up to $400 mail service
|
30% up to $200 copay per prescription + 25% of purchase price |
| *prescriptions filled at the pharmacy (in-Network) are for 30-day supply, Mail service is 90-day supply and is only available through Blue Shield’s network mail service vendor. | |||||
Kaiser
|
Northern California
|
Southern California
|
|
| Life and AD&D |
$10,000 for all active employees
|
|
| Lifetime Maximum Medical Benefit |
unlimited
|
unlimited
|
| Calendar Copayment Maximum |
$1,500 person
$3,000 family
|
$1,500 person
$3,000 family
|
| Physician Office Visits |
$15 per visit
|
$10 per visit
|
| Maternity Office Visits |
no charge
|
no charge
|
| Hospital Services |
no charge
|
no charge
|
| Skilled Nursing Facility |
100 days at no charge
|
100 days at no charge
|
| Diagnostic Lab & X-ray |
no charge
|
no charge
|
| Mental Health – Outpatient |
$15 per visit, $7 group visit
|
$10 per visit, $5 per group visit
|
| Mental Health – Inpatient |
no charge
|
no charge
|
| Substance Abuse – Inpatient/Outpatient |
$15 per visit, $5 per group visit, no charge for other services
No charge inpatient
|
$10 per visit, $5 per day for other services
|
| Emergency Room Services |
$50 copay per qualified ER visit
|
$35 copay per qualified ER visit
|
| Prescription Drugs |
$10 copay all tiers for 100-day supply retail or mail order
Specialty drugs: Up to a 30-day supply retail
|
$10 copay all tiers for 100-day supply retail or mail order
Specialty drugs: Up to a 30-day supply retail
|
| Durable Medical Equipment | No charge – requires prior authorization- covered only if prescribed and in accordance with DME formulary | |