| Network |
See Provider |
See Provider |
| Application |
Shield Spectrum PPO Savings Plan 4000 Application |
Shield Spectrum PPO Savings Plan 4000 Application |
| Brochure |
Shield Spectrum PPO Savings Plan 4000 Brochure |
Shield Spectrum PPO Savings Plan 4000 Brochure |
| Copay |
N/A |
N/A |
| Office Visit |
No charge after deductible |
50% |
| Deductible |
Services with preferred providers: $4,000 ($8,000 family) |
Services with non-preferred providers: $5,000 ($10,000 family) |
| Coinsurance |
No charge after deductible at preferred providers |
50% with non-preferred providers |
| Coinsurance Limit |
Shield Spectrum PPO Savings Plan 4000 |
Shield Spectrum PPO Savings Plan 4000 |
| Out-of-Pocket Maximum |
Services with preferred providers: $4,000 ($8,000 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: No charge after deductible
- Formulary Brand-Name Drugs: No charge after deductible
- Non-Formulary Brand-Name Drugs: No charge after deductible
Mail Services Prescriptions (Up to a 60-day supply) -- Generic Formulary Drugs: Covered at same level as participating pharmacies
- Formulary Brand-Name Drugs: Covered at same level as participating pharmacies
- Non-Formulary Brand-Name Drugs: Covered at same level as participating pharmacies
|
At Participating Pharmacies (Up to a 30-day supply) -- Generic Formulary Drugs: No charge after deductible
- Formulary Brand-Name Drugs: No charge after deductible
- Non-Formulary Brand-Name Drugs: No charge after deductible
Mail Services Prescriptions (Up to a 60-day supply) -- Generic Formulary Drugs: Covered at same level as participating pharmacies
- Formulary Brand-Name Drugs: Covered at same level as participating pharmacies
- Non-Formulary Brand-Name Drugs: Covered at same level as participating pharmacies
|
| 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): No charge after deductible
- 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 preferred provider
- Ambulance Services (Surface or air): Covered at same level as preferred provider
|
| Adult Preventative Care |
Annual Routine Physical Exam and Gynecological Exam (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 and well-baby care office visits: Not covered |
| Child Preventative Care |
Annual routine physical exam and well-baby care office visits: $0 |
Annual routine physical exam and 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: Not covered
- Delivery and all Necessary Inpatient Hospital Services: Not covered
|
| Physical Therapy |
Rehabilitation Services -- Provided in the Office of a Physician or Physical Therapist (Up to 20 visits per calendar year): No charge after deductible
Chiropractic Services (Blue Shield's payment is limited to $25/visit): No charge after deductible (Up to 12 visits per calendar year) |
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/visit): 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 (Up to 20 visits per calendar year combined with chemical dependency visits): No charge after deductible
Chemical Dependency Services (Substance abuse) -- Inpatient Hospital Facility Services 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 (Up to 20 visits per calendar year combined with chemical dependency visits): Not covered
Chemical Dependency Services (Substance abuse) -- Inpatient Hospital Facility Services 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 4000 |
Shield Spectrum PPO Savings Plan 4000 |
