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Medical – Blue Shield
Available to variable hour, temporary, part-time or seasonal employees and their dependent children only.
Blue Shield PPO
Two Tiered Anchor Bronze
In-Network
Out-Of-Network
Annual Deductible
Individual
Family
$5,000
$10,000
Annual Out-of-Pocket Max
Individual
Family
$6,350
$12,700
Lifetime Max
Unlimited
Unlimited
Office Visit
Plan pays 50% after deductible
Physician & specialist
$60 per visit
1
(For the 1
st
3 visits, thereafter plan pays
70% after deductible)
Plan pays 70% after deductible
2
Preventive Services
Plan pays 100%
Not Covered
Chiropractic Care
(up to 20 visits per calendar year)
Plan pays 70% after deductible
(up to 20 visits per year)
Not Covered
Lab and X-ray
Plan pays 70% after deductible
Not Covered
Inpatient Hospitalization
Plan pays 70% after deductible
Plan pays up to $600 per day.
Member is responsible for all
charges in excess.
Outpatient Surgery
Plan pays 70% after deductible
Plan pays up to $350 per day.
Member is responsible for all
charges in excess.
Emergency Room
$100 copay then plan pays 70% after deductible
(copay waived if admitted)
Ambulance (Ground or Air)
$100 copay then plan pays 70% after deductible
1
Not subject to deductible until 12.31.2017.
2
Starting January 1
st
, 2018, copays will no longer be apply. Office visits will be subject to deductible. 30% coinsurance will then apply
once deductible is met.
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.