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MEDI CAL , COnt i nued
PPO Plan
Blue Shield PPO
In-Network
Out-of-Network
Plan Year Deductible
Individual
Family
$750
$1,500
$1,500
$3,000
Plan Year Out-of-Pocket Max
Individual
Family
$4,750
$9,500
$9,500
$19,000
Preventive Services
No Charge
Not Covered
Office Visits
Primary Care Physician (PCP)
Specialist
Chiropractic Services
(limited to 12 visits per year)
$25 copay
$25 copay
$25 copay
40% after deductible
40% after deductible
40% after deductible
Urgent Care
$25 copay
40% after deductible
Lab and X-ray
CT, MRI, PET scans
Other labs and x-ray tests
$25 copay (lab) / $50 copay
(outpatient)
$25 copay (lab) / $50 copay
(outpatient)
40% after deductible (limited to $350/day)
40% after deductible (limited to $350/day)
Inpatient Hospitalization
$100 copay + 20% coinsurance
40% after deductible (limited to $600/day)
Outpatient Surgery
20% after deductible
40% after deductible (limited to $350/day)
Emergency Room
$100 copay + 20% coinsurance
(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 + 25%
$30 copay + 25%
$50 copay + 25%
20% up to $200 per prescription
Mail Order Pharmacy (90
days)
Generic
Preferred Brand
Non-Preferred Brand
$20 copay
$60 copay
$100 copay
Not Covered
Not Covered
Not Covered
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