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Medical – Blue Shield
Blue Shield PPO 100%
Plan A $20 copay
Blue Shield PPO 80%
Plan K $30 copay
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Annual Deductible
Individual
Family
$0
$0
$1,000
$2,000
Annual Out-of-Pocket
Max
Individual
Family
$1,000
$3,000
$3,000
$6,000
Lifetime Max
Unlimited
Unlimited
Unlimited
Unlimited
Office Visit
Primary Provider
$20 copay
Plan pays 50%
$30 copay
Plan pays 50%
after deductible
Specialist
$20 copay
Plan pays 50%
$30 copay
Plan pays 50%
after deductible
Preventive Services
Plan pays 100%
Not Covered
Plan pays 100%
Not covered
Chiropractic Care
(up to 20 visits per
calendar year)
Plan pays 100%
Not Covered
Plan pays 80% after
deductible
Not Covered
Lab and X-ray
Plan pays 100%
Not Covered
Plan pays 80% after
deductible
Not Covered
Inpatient
Hospitalization
Plan pays 100%
Plan pays up to $600
per day.
Member is responsible
for all charges in
excess.
Plan pays 80% after
deductible
Plan pays up to
$600 per day.
Member is
responsible for all
charges in excess.
Outpatient Surgery
Plan pays 100%
Plan pays up to $350
per day.
Member is responsible
for all charges in
excess.
Plan pays 80% after
deductible
Plan pays up to
$350 per day.
Member is
responsible for all
charges in excess.
Urgent Care
$20 copay
Plan pays 50%
$30 copay
Plan pays 50%
Emergency Room
$100 copay then plan pays 100%
(copay waived if admitted)
$100 copay then plan pays 80%
(copay waived if admitted)
Ambulance (Ground
or Air)
$100 copay then plan pays 100%
$100 copay then plan pays 80%
The information in this booklet is a general outline of the benefits offered under College of Marin benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.