Healthcare + Savings HDHP - Group ID: W0051428, Plan ID: PPOX0004
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only: $35.00
Employee & Spouse/Partner: $258.40
Employee & Children: $221.17
Employee & Family: $356.46
Out of Area Plan(Full-Time Employee * Contribution Per Pay Period)
Employee Only: $11.04
Employee & Spouse/Partner: $181.46
Employee & Children: $155.31
Employee & Family: $250.33
Employee & Spouse/Partner: $258.40
Employee & Children: $221.17
Employee & Family: $356.46
Out of Area Plan(Full-Time Employee * Contribution Per Pay Period)
Employee Only: $11.04
Employee & Spouse/Partner: $181.46
Employee & Children: $155.31
Employee & Family: $250.33
Part-Time Employee * Contribution Per Pay Period
Employee Only: $341.11
Employee & Spouse/Partner: $791.72
Employee & Children: $678.73
Employee & Family: $1093.56
Out of Area Plan(Part-Time Employee * Contribution Per Pay Period)
Employee Only: $239.04
Employee & Spouse/Partner: $577.95
Employee & Children: $495.37
Employee & Family: $798.10
Employee & Spouse/Partner: $791.72
Employee & Children: $678.73
Employee & Family: $1093.56
Out of Area Plan(Part-Time Employee * Contribution Per Pay Period)
Employee Only: $239.04
Employee & Spouse/Partner: $577.95
Employee & Children: $495.37
Employee & Family: $798.10
Lifetime maximum
No maximum
Plan Year
2022
Pre-Authorization Requirement
Pre-authorization required for all hospital stays and certain outpatient procedures.
PENALTY for not pre-authorizing: benefit may be denied in full for failure to pre-authorize.
PENALTY for not pre-authorizing: benefit may be denied in full for failure to pre-authorize.
Offered To
Employees
Care Management
Participation in care management optional
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Body/Description
You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.
When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.
This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.
Coinsurance
Network: 100% for preventive care; 80% after deductible for all other services, including prescriptions
Non-Network: 60% of allowed charges after deductible, including prescriptions
Non-Network: 60% of allowed charges after deductible, including prescriptions
Office co-pay
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Deductible
$1,750 per individual coverage/$3,500 per family coverage
Combined Network or Non-Network. Up to $2,800 of an individual's claims will apply toward the family deductible, and once that threshold is met the plan will begin sharing the costs for that individual.
Combined Network or Non-Network. Up to $2,800 of an individual's claims will apply toward the family deductible, and once that threshold is met the plan will begin sharing the costs for that individual.
Benefit Type
Medical
Annual maximum
$3,750 per individual/$7,500 per family
Combined Network or Non-Network
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
Combined Network or Non-Network
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
X-rays
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Maternity Hospital Stay
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Baby's First Exam
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Birthing Centers
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Midwives
Network: 80% after deductible
Non-Network: 80% after deductible
Non-Network: 80% after deductible
Prenatal Visits
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Doctor Delivery Charge
Covered the same as all other inpatient surgery
Reproductive Health
Network: 80% after deductible
Non-Network: 80% after deductible. If services are not available within 100 miles of the member home zip code travel expenses (airfare, mileage, rental car, lodging and meals) will be reimbursable after the deductible up to $10,000 per year.
Non-Network: 80% after deductible. If services are not available within 100 miles of the member home zip code travel expenses (airfare, mileage, rental car, lodging and meals) will be reimbursable after the deductible up to $10,000 per year.
Mental Health
INPATIENT CARE
Pre-Certification is required by you or your provider.
Network: 80% after deductible
Non-Network: 60% of billed charges
ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible.
Non-Network: 80% of billed charges after deductible (up to $300 maximum allowed charges) for professional services only.
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Pre-Certification is required by you or your provider.
Network: 80% after deductible
Non-Network: 60% of billed charges
ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible.
Non-Network: 80% of billed charges after deductible (up to $300 maximum allowed charges) for professional services only.
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Autism
Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.
Substance Abuse
Pre-certification is required by you or your provider.
INPATIENT CARE
Network: 80% after deductible
Non-Network: 60% after deductible
ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible
Non-Network: 80% of billed charges after deductible (up to $300 maximum allowed charges) for professional services only.
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
INPATIENT CARE
Network: 80% after deductible
Non-Network: 60% after deductible
ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible
Non-Network: 80% of billed charges after deductible (up to $300 maximum allowed charges) for professional services only.
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Acupuncture
Network: 80% after deductible
Non-Network: 60% after deductible
Up to 20 combined Network and Non-Network visits per year
Non-Network: 60% after deductible
Up to 20 combined Network and Non-Network visits per year
Allergy Tests
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Allergy Treatment
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Alternative Medicine
Not covered
Ambulance charges
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
CT Scans
100% **Pre authorization requirement
Chiropractors
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Coverage limited to certain conditions only. Contact Blue Shield for more information.
Emergency Room
Network: 80% after deductible
Non-Network: 80% after deductible
Lab/ancillary/professional charges paid at 80% after deductible for Network or Non-Network
Non-Network: 80% after deductible
Lab/ancillary/professional charges paid at 80% after deductible for Network or Non-Network
Urgent Care
Network: 80% after deductible;Non-Network: 60% after deductible
Hearing Care
Exam: Network: 100% as part of preventive care
Non-Network: Not covered
Hearing aids not covered
Non-Network: Not covered
Hearing aids not covered
Home Health Care
Network: 80% after deductible - 100 days per calendar year. Prior authorization required.
Non-Network: not-covered
Non-Network: not-covered
Hospice Care
Network: 80% after deductible
Non-Network: 80% after deductible
Non-Network: 80% after deductible
Hospital Stay
Pre-Certification required by you or your provider.
Network: 80% after deductible
Non-Network: 60% after deductible
Network: 80% after deductible
Non-Network: 60% after deductible
Infertility Treatment
Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
Non-Network: Not covered
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: Covered under Medical Lifetime Maximum on Drugs, $5000 see Pharmacy
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Non-Network: Not covered
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: Covered under Medical Lifetime Maximum on Drugs, $5000 see Pharmacy
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Laboratory Charges
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Magnetic resonance imaging - MRI
Pre-Certification required by you or your provider.
Network: 80% after deductible
Non-Network: 60% after deductible
Network: 80% after deductible
Non-Network: 60% after deductible
Durable Medical Equipment
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Occupational Therapy
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Organ Transplants
Contact Blue Shield for information on transplant coverage benefits
Skilled Nursing
Network: 80% after deductible
Non-Network: 80% after deductible (pre-certification required)
Up to a 120-day annual maximum Network and Non-Network combined.
Non-Network: 80% after deductible (pre-certification required)
Up to a 120-day annual maximum Network and Non-Network combined.
Physical Therapy
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Surgery : Physician Services
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Surgery : Facility Charges
Network: 80% after deductible
Non-Network (non-ambulatory surgery centers): 60% of billed charges after deductible
Non-Network (ambulatory surgery centers): 60% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit
For example, if the non-network allowed charge is $4,500, the plan will pay 60% of {the lesser of $4,000 or the allowed charge} = 60% x $4,000 = $2,400.
Non-Network (non-ambulatory surgery centers): 60% of billed charges after deductible
Non-Network (ambulatory surgery centers): 60% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit
For example, if the non-network allowed charge is $4,500, the plan will pay 60% of {the lesser of $4,000 or the allowed charge} = 60% x $4,000 = $2,400.
Speech Therapy
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Tubal Ligation
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Vasectomy
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
X-rays
Network: 80% after deductible
Non-Network: 60% after deductible
Non-Network: 60% after deductible
Pharmacy (Retail)
Network or Non-Network: 80% after deductible (90-day supply of maintenance drugs available at Retail Pharmacy
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Fertility drugs: covered at 50% after deductible; max benefit of $5,000 per lifetime
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Fertility drugs: covered at 50% after deductible; max benefit of $5,000 per lifetime
Mail order drug program
80% after deductible; Specialty drugs are not available via mail order.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service.
Birth Control Pills
Included in Prescription Drug benefit
Physical exams for adults
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Physical exams for children
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Pap smears
Network: 100% if part of annual preventive
Non-Network: Not covered
Non-Network: Not covered
Mammograms
Network: 100% if part of annual preventive
Non-Network: Not covered
Non-Network: Not covered
Immunizations
Network: 100%
Non-Network: not covered;
Travel immunizations are covered both in-network and out of network at no charge
Non-Network: not covered;
Travel immunizations are covered both in-network and out of network at no charge
Prostate Specific Antigen test - PSA
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Well-woman visits
Network: 100%
Non-Network: Not covered
Non-Network: Not covered
Vision care
Network: 100%
Non-Network: Not covered
Limited to screen and refraction exams only
Non-Network: Not covered
Limited to screen and refraction exams only