Employees are 100% covered and the first dependent has 50% coverage.

Overview

$1,000 per individual / $2,000 per family for out of network | $250 per individual / $500 per family for all networks. | $0 | | Out-of-pocket limit for in-network | $5,000 per individual / $10,000 per family | $3,500 per individual / $7,000 per family | $2,300 per individual / $4,600 per family | | Primary care visit for in-network | No charge | $10/visit; deductible does not apply | $20/visit | | Need a referral to see a specialist? | No | No | Yes | | Diagnostic test for in-network | Lab & Path: $20/visit X-Ray & Imaging: $30/visit Other Diagnostic Examination: $30/visit | Lab & Path: $20/visit X-Ray & Imaging: $35/visit Other Diagnostic Examination: $35/visit | Lab & Path: $20/visit X-Ray & Imaging: $40/visit Other Diagnostic Examination: $40/visit | | Rx Tier 1 for in-network | Retail: No Charge Mail Service: No Charge | Retail: $10/prescription; deductible does not apply

Mail Service: $20/prescription; deductible does not apply | Retail: $5/prescription Mail Service: $10/prescription | | If you are pregnant for in-network | Office Visit: No Charge

Childbirth/delivery services: 10% coinsurance

Childbirth/delivery facility services: 10% coinsurance | Office Visit: No Charge; deductible does not apply

Childbirth/delivery services: 10% coinsurance

Childbirth/delivery facility services: 10% coinsurance | Office Visit: No Charge

Childbirth/delivery services: No Charge

Childbirth/delivery facility services: $500/admission |

Plan cost per member by age

• Blue Shield Platinum Full PPO 0/0 Cost
• Blue Shield Platinum Full PPO 250/10 Cost
• Blue Shield Platinum Access+ HMO 0/20

What do employees usually choose?

People who expect to visit the doctor more tend to choose Full PPO 0/0. Otherwise they typically choose PPO 250/10 Cost.