Blue Shield PPO

Plan Summary

Deductibles & Maximums
	Preferred Providers	Non-Preferred Providers
Calendar Year medical deductible	$250 per individual/$500 per family
Calendar Year copayment maximum	$2,000 per individual/$4,000 per family	$10,000 per individual/$20,000 per family
Lifetime Maximum	$6,000,000
Professional Services
Physician Services Physician & Specialist Office Visits Laboratory and X-rays Allergy Testing or treatment Diagnostic Testing	$15/visit (deductible waived) $15/visit 10% copayment 10% copayment	30% copayment 30% copayment 30% copayment 30% copayment
Preventive Care Annual routine physical examination, eye/ear screenings and immunizations Laboratory, including mammogram and Pap test screening or other FDA approved cervical cancer screening test (one per calendar year)	$15/visit (deductible waived)	not covered
Well-baby Care Office visits & consultations (includes: eye/ear screenings, immunizations, vaccinations) Laboratory	$15/visit (deductible waived) $15/visit	not covered
Outpatient Services
The maximum allowed charge for non-emergency surgery & services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $250 per day. Members are responsible for 30% of this $350 per day, plus all charges in excess of $350.
Outpatient surgery peformed in a Participating Ambulatory Surgery Center (ASC)	10% copayment	30% copayment
Outpatient surgery in a hospital/facility	10% copayment	30% copayment
Outpatient treatment and necessary supplies	10% copayment	30% copayment
Hospitalization Services
Inpatient Services - Non-Emergency Inpatient physician services (including pregnancy and maternity care) Semi-private room and board, medically necessary services and supplies Bariatric surgery (pre-authorization required; medically necessary surgery for weight loss, only for morbid obesity)	10% copayment	30% copayment
Skilled Nursing Facility (SNF) services (Combined maximum of up to 100 preauthorized days per calendar year; semi-private accomodations) Freestanding SNF Hospital SNF Unit	10% copayment 10% copayment	10% with prior authorization 30% copayment
Emergency Health Coverage
ER facility services (deductible and coinsurance waived if the member is admitted directly from ER for inpatient services)	$50 + 10%
Inpatient Facility services (when the member is admitted directly from the ER)	10% copayment	10% copayment
ER physician visits	10% copayment	10% copayment
Ambulance services	10% copayment	10% copayment
Prosthetics/Orthotics	10% copayment	30% copayment
Durable Medical Equipment (Plan pays up to $2000 per calendar year)	10% copayment	30% copayment
Mental Health Services
Inpatient	10% copayment	30% copayment
Outpatient (severe)	$15/visit (deductible waived)	30% copayment
Outpatient (non-severe) (up to 20 visits per calendar year combined with outpatient chemical dependency visits)	$25/visit	not covered
Chemical Dependency Services (Substance Abuse)
Inpatient Services for medical acute detoxification	see Hospitalization Services	see Hospitalization Services
Outpatient Visits (up to 20 visits per calendar year combined with outpatient non-severe mental health visits)	$25/visit	not covered
Prescription Drugs
Retail Prescriptions	$10/Generic $20/Formulary $35/Non-Formulary	25% of allowble amount plus copayment of: $10/Generic $20/Formulary $35 Non-Formulary
Mail Service	$20/Generic $40/Formulary $60/Non-Formulary	not covered
Injectables (self-administered)	30% (up to $150 copayment maximum per prescription)	not covered

This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.