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Access to care highlights

PPO PLAN
WITH VIRTUAL BLUE
EPO PLAN
WITH VIRTUAL BLUE
HDHP PPO PLAN
WITH VIRTUAL BLUE
Network
Virtual + VB PPO + non-network providers
Virtual + VB PPO
Virtual + VB PPO + non-network providers
Access to in-person doctors, hospitals, etc.
Visit any doctor you choose
Visit any doctor in the PPO network
Visit any doctor you choose
Deductible: Individual
$500 (network + non-network)
$500
$5,000 (network + non-network)
Deductible: Family
$500: individual (network + non-network)
$1,000: family (network + non-network)
$500: individual
$1,500: family
$5,000: individual (network + non-network)
$10,000: family (network + non-network)
Out-of-pocket maximum:
In-network: Individual
$2,500
$3,500
$6,000 (network + non-network)
In-network: Family
$2,500: individual
$5,000: family
$3,500: individual
$7,000: family
$6,000: individual (network + non-network)
$12,000: family (network + non-network)
Out-of-network: Individual
$3,500
N/A
Combined with in-network deductible
Out-of-network: Family
$3,500: individual
$7,000: family
N/A
Combined with in-network deductible

Medical benefits

PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
EPO PLAN
WITH VIRTUAL BLUE
HDHP PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
Costs per office visit / admission
In-network
Out-of-Network
In-network
In-network
Out-of-Network
Preventive health exam
$0
50%*
$0
$0
Not covered
Virtual Blue virtual providers: PCP/specialist visit
$0
N/A
$0
$0
N/A
Primary Care visit
$25
50%*
$25
20%*
50%*
Specialist visit
$35
50%*
$35
20%*
50%*
Specialist office visit (HMO self-referral)*
N/A
N/A
N/A
N/A
N/A
Prenatal and postnatal visit
$25
50%*
$25
20%*
50%*
Virtual Blue virtual providers: mental health
$0
50%
$0
$0
N/A
Mental health visit
$0
50%
$0
20%*
50%*
Mental health outpatient services
$0*
50%
$0*
$0*
50%*
Substance abuse outpatient services
$0*
50%
$0*
20%*
50%*
Substance abuse inpatient facility
$500 + 20%*
50%*
$500 + 20%*
$100 + 20%*
50%*
Lab work
$0
50%
$25
20%*
50%*
Outpatient surgery (facility services)
$0*
$500 + 50% (max benefit: $2,000 per day)*
$250*
20%*
50% (max benefit:
of $350/day)*
Inpatient hospital services and stay
$500 + 20%*
$500 + 50% (max benefit: $2,000 per day)*
$500 + 20%*
$100 + 20%*
50%* (max benefit
of $600/day)
Urgent care services
$25
50%*
$25
20%*
50%*
Emergency room services
$125 +20%
$125 +20%
$125 + 20%
$150 + 20%*
$150 + 20%*
Acupuncture services
$25
50%*
$25
20%*
50%*
Chiropractic services
$25
50%*
$25
20%*
50%*

Pharmacy benefits

PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
EPO PLAN
WITH VIRTUAL BLUE
HDHP PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
Costs per fill
In-network
Out-of-Network
In-network
In-network
Out-of-Network
Pharmacy deductible
None
None
None
Combined with medical
Combined with medical
Retail pharmacy (30-day supply / prescription)
Contraceptive drugs/devices
$0
Cost based on tier
$0
$0
Cost based on tier
Preventive drugs (value-based or HDHP)
$0
Not covered
$0
$0
Not covered
Tier 1 drugs
$10
$10 + 25% of cost
$10
$10*
$10 + 25% *
Tier 2 drugs
$25
$25 + 25% of cost
$25
$25*
$25 + 25% of cost*
Tier 3 drugs
$40
$40 + 25% of cost
$40
$40*
$40 + 25% of cost*
Tier 4 drugs
$40
$40 + 25% of cost
$40
$40*
$40 + 25% of cost*
Mail-service pharmacy (90-day supply / prescription)
Contraceptive drugs/devices
$0
Not covered
$0
$0
Not covered
Preventive drugs (value-based or HDHP)
$0
Not covered
$0
$0
Not covered
Tier 1 drug
$20
Not covered
$20
$20*
Not covered
Tier 2 drugs
$50
Not covered
$50
$50*
Not covered
Tier 3 drugs
$80
Not covered
$80
$80*
Not covered
Tier 4 drugs
$80
Not covered
$80
$80*
Not covered

* Calendar-year deductible applies. This is the amount a Member pays each calendar year before Blue Shield pays for covered services under the Plan. Blue Shield pays for some covered services before the calendar year deductible is met, as noted in the benefits chart above.

** Self-referral to specialists may be available to members of participating medical groups – no need to see your primary care physician first. Please see your plan's Evidence of Coverage for more details.