Blue Shield Preferred Medical Plans
| Preferred Plan Name | |||
|---|---|---|---|
| Medical Plan Design | PPO-812 | PPO-815 | PPO-829 |
| In-Network | |||
| Deductible | N/A | N/A | $250/$500 |
| Coinsurance | N/A | N/A | 0.1 |
| Out of Pocket Maximum | $6,350/$12,700 | $6,350/$12,700 | $1,000/$2,000 |
| Office Visit Copay | 10 | 25 | $25/$40 |
| Emergency Room Copay | 50 | 100 | 150 |
| Urgent Care Copay | 10 | 25 | 40 |
| Inpatient Copay | 0 | $250 PA | Deductible & Coinsurance |
| Outpatient Copay | 0 | 200 | Deductible & Coinsurance |
| Out-of-Network | |||
| Deductible | $250/$500 | $500/$1,000 | $500/$1,000 |
| Coinsurance | 0.2 | 0.3 | 0.3 |
| Out of Pocket Maximum | $2,500/$5,000 | $2,500/$5,000 | $2,500/$5,000 |
Preferred Pharmacy Plans (Currently with CVS/Caremark)
| Benefit Option Name | Retail Copay/Coinsurance per Prescription Fill (30-Day Supply) | Mail Copay/Coinsurance per Prescription Fill (90-Day Supply) |
||||
|---|---|---|---|---|---|---|
| Tier 1 | Tier 2 | Tier 3 | Tier 1 | Tier 2 | Tier 3 | |
| Preferred Plan 1 | 0 | 15 | 30 | 0 | 30 | 60 |
| Preferred Plan 2 | 5 | 25 | 40 | 10 | 50 | 80 |
| Preferred Plan 3 | 0.2 | 0.2 | 0.2 | 0.2 | 0.2 | 0.2 |
| Preferred Plan 4 | 10 | 30 | 50 | 20 | 60 | 100 |
| Preferred Plan 5 | 15 | 35 | 60 | 30 | 70 | 120 |
| Preferred Plan 6 | 0.3 | 0.3 | 0.3 | 0.3 | 0.3 | 0.3 |