|
Plan name: |
Blue Shield CDHP |
| Plan year: |
2022 |
|
Group number: |
W0002517 |
|
Carrier: |
Blue Shield of California |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
In-Network |
Out-of-Network | |
|
Annual Deductible *Combined with out-of-network |
Individual: $1,500* Family: $2,800 per individual, up to $3,000 per family* | Individual: $1,500* Family: $2,800 per individual, up to $3,000 per family* |
| Annual Out-of- Pocket Max | $3,000 per individual, up to $6,000 per family | $6,000 per individual, up to $12,000 per family |
|
Office Visit Primary Provider Specialist |
You pay 10% after deductible You pay 10% after deductible |
You pay 30% after deductible You pay 30% after deductible |
| Preventive Services | No charge (deductible waived) | Not covered |
| Chiropractic Care | You pay 10% after deductible (limited to 20 visits per calendar year*) | You pay 50% after deductible (limited to 20 visits per calendar year*) |
|
Lab & X-Ray Copays and limits may apply based on setting of care |
You pay 10% after deductible |
You pay 30% after deductible |
| Inpatient Hospitalization |
$100 per admission + You pay 10% after deductible |
You pay 30% after deductible (coverage limited to $600 per day) |
| Infertility Benefits | You pay 20% after deductible | Not covered |
| Emergency Room |
$100 per admission + You pay 10% after deductible |
$100 per admission + You pay 10% after deductible |
| Retail Pharmacy | ||
| Tier 1 |
$10 copay after deductible |
$10 copay + you pay 25% after deductible |
| Tier 2 | $30 copay after deductible | $30 copay + you pay 25% after deductible |
| Tier 3 | $50 copay after deductible | $50 copay + you pay 25% after deductible |
|
Tier 4 (excluding specialty) |
30% up to $250/Rx after deductible | 25% of purchase price + 30% up to $200/Rx after deductible |
| Supply Limit | 30 days | 30 days |
| Mail Order | ||
| Tier 1 |
$20 copay after deductible |
Not covered |
| Tier 2 |
$60 copay after deductible |
Not covered |
| Tier 3 |
$100 copay after deductible |
Not covered |
|
Tier 4 (excluding specialty) |
30% up to $500/Rx after deductible | Not covered |
| Specialty | 30% up to $250/Rx after deductible | Not covered |
| Supply Limit | 90 days | Not covered |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Employee Rates (monthly) |
Rate |
|
Employee Only |
$60.00 |
|
Employee + 1 |
$180.00 |
|
Employee + Child(ren) |
$160.00 |
|
Family |
$272.00 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Title/Department: |
Blue Shield Member Services |
|
State: |
CA |
|
Phone: |
888-256-1915 |
|
URL: |
|
Title/Department: |
Blue Shield Member Services |
|
State: |
Outside CA |
|
Phone: |
888-256-1915 |
|
URL: |
|
Title/Department: |
Health Equity HSA Member Services |
|
State: |
|
|
Phone: |
877-857-6810 |
|
URL: |
http://www.healthequity.com |