|
Plan name: |
Blue Shield PPO |
|
Plan year: |
2022 |
|
Group number: |
W0002517PPOX0002 |
|
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: $500 Family: $1,000 | Individual: $1,000 Family: $2,000 |
| Annual Out-of- Pocket Max | $2,000 per individual, up to $4,000 per family* | $4,000 per individual, up to $8,000 per family |
| Office Visit
Primary Provider Specialist |
$20 copay
$40 copay |
You pay 30% after deductible
You pay 30% after deductible |
| Preventive Services | No charge (deductible waived) | Not covered |
| Chiropractic Care | $25 per visit (coverage limited to 20 visits per calendar year*) | You pay 30% after deductible (coverage limited to 20 visits per calendar year*) |
| Lab & X-Ray
Copays and limits may apply based on setting of care |
$10 copay | You pay 30% after
deductible |
| Inpatient Hospitalization | 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 visit (copay waived if admitted; deductible waived) | $100 per visit (copay waived if admitted; deductible waived) |
|
Retail Pharmacy |
||
| Tier 1 | $10 copay | $10 copay + you pay
25% |
| Tier 2 | $30 copay | $30 copay + you pay 25% |
| Tier 3 | $50 copay | $50 copay + you pay 25% |
| Tier 4
(excluding specialty) |
30% up to $250/Rx | 25% of purchase price + 30% up to $200/Rx |
| Supply Limit | 30 days | 30 days |
| Mail Order | ||
| Tier 1 | $20 copay | Not covered |
| Tier 2 | $60 copay | Not covered |
| Tier 3 | $100 copay | Not covered |
| Tier 4
(excluding specialty) |
30% up to $500/Rx | Not covered |
| Specialty | 30% up to $250/Rx | 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 | $194.00 |
|
Employee + Spouse |
$422.00
|
|
Employee + Child(ren) |
$382.00 |
|
Family |
$634.00
|
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 of CA |
|
Phone: |
888-256-1915 |
|
URL: |
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.