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MEDI CAL - hmo
s
The HydraFacial Company offers you medical plan options through Blue Shield of California. The
following pages will give you a summary and comparison of each plan.
California Employees
•
HMO Access+ SaveNet
•
HMO Access+ Full Network
•
PPO Standard
•
PPO HDHP w/ HSA
Key Benefits
Access+ HMO SaveNet
Access+ HMO Full Network
In-Network
In-Network
Annual Deductible
Individual
Family
None
None
None
None
Annual Out-of-Pocket Max
Individual
Family
$3,000
$6,000
$3,000
$6,000
Preventive Services
No Charge
No Charge
Office Visits
Primary Care Physician (PCP)
Specialist
$25 copay
$25 copay
$25 copay
$25 copay
Access+ Specialist
SM
$40 copay
$40 copay
Urgent Care
$25 copay
$25 copay
Lab and X-ray
CT, MRI, PET scans
Other labs and x-ray tests
No Charge
No Charge
Inpatient Hospitalization
$100 copay + 25% coinsurance
$100 copay + 25% coinsurance
Outpatient Surgery
25% coinsurance
25% coinsurance
Emergency Room
$100 copay
(copay waived if admitted)
$100 copay
(copay waived if admitted)
Prescription Drugs (30 days)
Generic
Preferred Brand
Non-Preferred Brand
Specialty Drugs
$10 copay
$30 copay
$50 copay
20% up to $200 per prescription
$10 copay
$30 copay
$50 copay
20% up to $200 per prescription
Mail Order Pharmacy (90 days)
Generic
Preferred Brand
Non-Preferred Brand
$20 copay
$60 copay
$100 copay
$20 copay
$60 copay
$100 copay
c a r r y o v e r
For the remainder of 2017, the amount
you have paid towards your deductible &
maximums will carry over to the new plan
so you are not starting over in October.
On January 1, 2018, a new plan year
begins with fresh calendar year
deductibles and maximums.
For California Employees Only, the primary difference between HMO
SaveNet & HMO Full Network is the network of providers for each plan.
Please note that HMO plans do not allow you to go out-of-network.
All other states
•
PPO Standard
•
PPO HDHP w/ HSA
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