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MEDI CAL
Medical coverage provides you with benefits that help keep you healthy like preventive care
screenings and access to urgent care. It also provides important financial protection if you have a
serious medical condition.
The HydraFacial Company offers you medical plan options through Blue Shield of California.
HMO Plans
Blue Shield
Access+ HMO SaveNet
Blue Shield
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
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
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