| Network |
See Provider |
See Provider |
| Application |
Shield Spectrum PPO Savings Plan 3500 Application |
Shield Spectrum PPO Savings Plan 3500 Application |
| Brochure |
Shield Spectrum PPO Savings Plan 3500 Brochure |
Shield Spectrum PPO Savings Plan 3500 Brochure |
| Copay |
N/A |
N/A |
| Office Visit |
No charge after deductible |
50% after deductible |
| Deductible |
Services with preferred providers: $3,500 ($7,000 family) |
Services with non-preferred providers: $5,000 ($10,000 family) |
| Coinsurance |
No charge after deductible with preferred providers |
50% with non-preferred providers |
| Coinsurance Limit |
Shield Spectrum PPO Savings Plan 3500 |
Shield Spectrum PPO Savings Plan 3500 |
| Out-of-Pocket Maximum |
Services with preferred providers: $5,000 ($10,000 family) |
Services with non-preferred providers: $15,000 ($30,000 family) |
| Lifetime Maximum |
$6,000,000 |
$6,000,000 |
| Prescription Drugs |
At Participating Pharmacies (Up to a 30-day supply) -- Generic Formulary Drugs: $10/prescription
- Formulary Brand-Name Drugs: $35/prescription
- Non-Formulary Brand-Name Drugs: $50 or 50%/prescription, whichever is greater (Maximum of $150/Rx)
Mail Service Prescriptions (Up to a 60-day supply) -- Generic Formulary Drugs: $20/prescription
- Formulary Brand-Name Drugs: $70/prescription
- Non-Formulary Brand-Name Drugs: $100 or 50%/prescription whichever is greater (Maximum of $300/Rx)
|
At Participating Pharmacies (Up to a 30-day supply) -- Generic Formulary Drugs: $10/prescription
- Formulary Brand-Name Drugs: $35/prescription
- Non-Formulary Brand-Name Drugs: $50 or 50%/prescription, whichever is greater (Maximum of $150/Rx)
Mail Service Prescriptions (Up to a 60-day supply) -- Generic Formulary Drugs: $20/prescription
- Formulary Brand-Name Drugs: $70/prescription
- Non-Formulary Brand-Name Drugs: $100 or 50%/prescription whichever is greater (Maximum of $300/Rx)
|
| Emergency Room |
Emergency Health Coverage -- Emergency Room Services ($75 or $100 copayment/visit is waived if the member is admitted directly to the hospital as an inpatient): $100/visit
- ER Physician Visits: No charge after deductible
- Ambulance Services (Surface or air): No charge after deductible
|
Emergency Health Coverage -- Emergency Room Services ($75 or $100 copayment/visit is waived if the member is admitted directly to the hospital as an inpatient): Covered at same level as preferred provider
- ER physician Visits: Covered at same level as provider
- Ambulance Services (Surface or air): Covered at same level as preferred provider
|
| Adult Preventative Care |
Annual Routine Physical Exam, Gynecological (Includes Pap test or other approved cervical cancer screening tests, and routine mammography when received as part of the annual exam or preventive care exam): $0 |
Annual Routine Physical Exam, Well-Baby Care Office Visits: Not covered |
| Child Preventative Care |
Annual Routine Physical Exam, Well-Baby Care Office Visits: $0 |
Annual Routine Physical Exam, Well-Baby Care Office Visits: Not covered |
| Lab / X-Ray |
Outpatient X-ray and Laboratory: No charge after deductible |
Outpatient X-ray and Laboratory: 50% |
| Maternity |
Pregnancy and Maternity Care -- Outpatient Prenatal and Postnatal Care: Not covered
- Delivery and all Necessary Inpatient Hospital Services: Not covered
|
Pregnancy and Maternity Care -- Outpatient Prenatal and Postnatal Care: 50%
- Delivery and all Necessary Inpatient Hospital Services: 50%
|
| Physical Therapy |
Rehabilitation Services -- Provided in the Office of a Physician or Physical Therapist (Up to 20 visits per calendar year): 70% (Visit limit per calendar year combined with chiropractic visits)
Chiropractic Services (Blue Shield's payment is limited to $25/visit): 70% (Up to 20 visits per calendar year combined with physical therapy visits) |
Rehabilitation Services -- Provided in the Office of a Physician or Physical Therapist (Up to 20 visits per calendar year): 50%
Chiropractic Services (Blue Shield's payment is limited to $25/visits): Not covered |
| Skilled Nursing |
N/A |
N/A |
| Home Health Care |
Home Health Services (Up to 90 pre-authorized visits per calendar year): No charge after deductible |
Home Health Services (Up to 90 pre-authorized visits per calendar year): Not covered |
| Mental Health |
Mental Health Services -- Inpatient Hospital Facility Services: No charge after deductible
- Inpatient Physician Services: No charge after deductible
- Outpatient Visits for Severe Mental Health Conditions: No charge after deductible
- Outpatient Visits for Non-Severe Mental Health Conditions (Up to 20 visits per calendar year combined with chemical dependency visits): No charge after deductible
Chemical Dependency Service (Substance abuse) -- Inpatient Hospital Facility for Medical Acute Detoxification: No charge after deductible
- Inpatient Physician Services for Medical Acute Detoxification: No charge after deductible
- Outpatient Visits (Up to 20 visits per calendar year combined with non-severe mental health visits): No charge after deductible
|
Mental Health Services -- Inpatient Hospital Facility Services: 50%
- Inpatient Physician Services: 50%
- Outpatient Visits for Severe Mental Health Conditions: 50%
- Outpatient Visits for Non-Severe Mental Health Conditions (Up to 20 visits per calendar year combined with chemical dependency visits): Not covered
Chemical Dependency Service (Substance abuse) -- Inpatient Hospital Facility for Medical Acute Detoxification: 50%
- Inpatient Physician Services for Medical Acute Detoxification: 50%
- Outpatient Visits (Up to 20 visits per calendar year combined with non-severe mental health visits): Not covered
|
| Hospital Care |
Hospitalization Services -- Inpatient Physician Visits and Consultations, Surgeons and Assistants, and Anesthesiologist: No charge after deductible
- Inpatient Semiprivate Room and Board, Services and Supplies, and Subacute Care: No charge after deductible
- Bariatric Surgery Inpatient Services (Pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): No charge after deductible
Outpatient Services -- Non-Emergency Services and Procedures, Outpatient Surgery in a Hospital: No charge after deductible
- Outpatient Surgery Performed in an Ambulatory Surgery Center (ASC): No charge after deductible
|
Hospitalization Services -- Inpatient Physician Visits and Consultations, Surgeons and Assistants, and Anesthesiologist: 50%
- Inpatient Semiprivate Room and Board, Services and Supplies, and Subacute Care: 50%
- Bariatric Surgery Inpatient Services (Pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): 50%
Outpatient Services -- Non-Emergency Services and Procedures, Outpatient Surgery in a Hospital: 50%
- Outpatient Surgery Performed in an Ambulatory Surgery Center (ASC): 50%
|
| Optional Benefits |
Shield Spectrum PPO Savings Plan 3500 |
Shield Spectrum PPO Savings Plan 3500 |
