Plan Options: Benefit Category Name Current Plan New Plan

plan options
The current plan you offer to employees is listed below. This plan is being withdrawn and is no longer available. Therefore, we have
identified a plan from our new portfolio, effective January 1, 2014, to recommend as a replacement. This new plan has the most similar
benefits to your current plan being offered. If you want to replace your plan offering with this recommended plan, just pay your bill
and youre set. We will transfer any employees enrolled into the recommended alternative plan.
You also have the choice to select other plans from Blue Shield. Please reference the Your Guide to 2014 Small Business Coverage Options
for additional plan details. Or talk to your broker or Blue Shield representative to find the plan(s) that best fits the needs of your small business.
Benefit category name
Current plan
New plan
Base PPO 30
Basic Full PPO for Small Business 4500*
Deductibles or out-of-pocket maximum

Calendar year medical deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year
medical deductibles.)
Participating providers1
Non-participating providers1
$3,000 per individual/$6,000 per family
Calendar year out-of-pocket maximum1 (Includes the calendar year medical plan deductible. Copayments for covered services from participating providers accrue to
both the participating and non-participating provider calendar year copayment maximums.)
Non-participating providers
$10,000 per member
$30 per visit
$45 per visit
50%
50%
No charge
(Not subject to calendar year
medical deductible)
No charge2
(Not subject to calendar year
medical deductible)
Not covered
Not covered
Professional services
Primary care doctor and specialist doctor office visits
Preventive health benefits

Non-participating providers1
Hospitalization services
Inpatient hospitalization 5 (Of up to $600/day + excess charges over $600/day for non-participating providers)
30%
40%
50%
50%
Emergency health coverage

Emergency room services not resulting in admission
$100 per visit1 + 30%
$200 per visit + 40%
Prescription drug coverage 1

Calendar year brand drug deductible
Retail prescriptions 4
(up to a 30-day supply)
$300
$500
Generic drugs
$10 per prescription
$25 per prescription3
Preferred brand drugs
Non-preferred
brand drugs
Contact your broker or a Blue Shield representative if you would like to choose a different
plan from the plan shown here.
This document is for summary purposes only. For additional plan details, please refer to the Benefit Summary Guide (A16609).
(see endnotes on reverse)
Endnotes

1 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a
percentage of allowable amounts. Participating providers accept Blue Shields allowable amount as full payment for covered
services. Non-participating providers can charge more than these amounts. When members use non-participating providers,
they must pay the applicable copayment plus any amount that exceeds Blue Shields allowable amount. Charges above the
allowable amount do not count toward the calendar year deductible or copayment maximum.
2 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar
year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care
or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/
coinsurance.
3 This plans prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal
government for Medicare Part D (also called creditable coverage). Because this plans prescription drug coverage is
creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you
should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible
to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D
premium.
4 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for
the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment.
The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and
is not included in the calendar year out-of-pocket maximum responsibility calculation.
5 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day.
Members are responsible for the coinsurance percentage of this $600 per day, plus all charges in excess of $600. Charges
that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum.
t Underwritten by Blue Shield of California Life & Health Insurance Company.
An independent member of the Blue Shield Association
A46030-A (1/14)
*
Pending regulatory approval.

Plan Options: Benefit Category Name Current Plan New Plan

Uploaded by

Copyright:

Available Formats

Plan Options: Benefit Category Name Current Plan New Plan

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Plan Options: Benefit Category Name Current Plan New Plan

Uploaded by

Copyright:

Available Formats

plan options

Benefit category name

Basic Full PPO for Small Business 4500*

Deductibles or out-of-pocket maximum

$3,000 per individual/$6,000 per family

$4,500 per individual/$9,000 per family

$6,000 per individual/$12,000 per family

$6,350 per individual/$12,700 per family

$10,000 per member

$10,000 per individual/$20,000 per family

$30 per visit

$45 per visit

Preventive health benefits

Emergency health coverage

$100 per visit1 + 30%

$200 per visit + 40%

$100 per visit + 30%

$200 per visit + 40%

Prescription drug coverage 1

$10 per prescription

$25 per prescription3

Preferred brand drugs

$30 per prescription

$50 per prescription3

$50 per prescription

$75 per prescription3

An independent member of the Blue Shield Association

You might also like