Cabrillo College - SISC Blue Shield Plans Comparion - Effective October 1, 2015
Member Pays
$3,000/$5,000
Blue Shield HMO
10-0, Rx 5-10
Member Pays
$0/$0
Blue Shield HMO
25-500, Rx 9-35
Member Pays
$0/$0
Blue Shield HMO
30-20%, Rx 9-35
Member Pays
$0/$0
$3,000/$6,000
$5,000/$10,000
$1,000/$2,000
$2,000/$4,000
$1,500/$3,000
$20
$20
$20
$20
20%
20%
Not covered
$30
$30
$30
$30
20%
20%
Not covered
10%
10%
10%
10%
10%
10%
Not covered
$10
$10
$10/$30
$0
$0
$0
50%
$25
$25
$25/$30
$0
$0
$0
50%
$30
$30
$30/$45
$0
$0
$0
50%
0%, Deductible Waived
0%, Deductible Waived
0%, Ded Waived
$0
$0
$0
20%
$100 co-pay
20%
20%
20%
$100 co-pay
20%
20%
10%
$100 co-pay
10%
10%
$100
$100
$150
$0
$0
$500/admit
$500/admit
20%
$0
20%
20%
10%
$0
$150
$0
20%
20%
10%
$0
$300
$0
20%
20%
10%
$0
$500/admit
20%
$20
$30
10%
$10
$25
$30
Acupuncture - Limits apply
20%
20%
10%
Ambulance (Ground or Air)
20%
20%
10%
Chiropractic - Limits apply
20%
20%
10%
Durable Medical Equipment (DME)
Physical and Occupational Therapy - Limits apply
20%
20%
20%
20%
10%
10%
$10/30 visits combined
w/chiro
Use ASH network
$100
$10/30 visits combined
w/acu
Use ASH Network
20%
$10
$10/30 visits combined
w/chiro
Use ASH network
$100
$10/30 visits combined
w/acu
Use ASH Network
20%
$25
$10/30 visits combined
w/chiro
Use ASH network
$100
$10/30 visits combined
w/acu
Use ASH Network
20%
$30
Blue Shield
After deductible,
$7/ 30-day
After deductible,
$25/30-day
After deductible,
$14-25/90-day
Medical OOP Maximum
applies
SISC PLAN NAME
Individual/Family Deductibles
Individual/Family Calendar Out-of-Pocket Max
(includes medical co-pays, deductibles and co-insurance)
PROFESSIONAL SERVICES
Office Visit co-pay
Urgent Care co-pay
Specialists/Consultants co-pay
Prenatal, postnatal office visit co-pay
Scans: CT, CAT, MRI, PET etc.
Diagnostic X-ray & Laboratory Procedures
Infertility (diagnosis/treatment of causes of infertility)
Preventive Care Services (includes physical exams &
screenings)
HOSPITAL & SKILLED NURSING FACILITY SERVICES
Emergency Room visit co-pay
(waived if admitted)
Inpatient Hospital co-pay (preauthorization required)
Outpatient Hospital co-pay
Surgery, Outpatient (performed in an Ambulatory Surgery
Center)
Surgery, Outpatient (performed in a Hospital)
MENTAL HEALTH SERVICES & SUBSTANCE ABUSE
TREATMENT
INPATIENT CARE: Facility based care (preauthorization
required)
OUTPATIENT CARE: Facility based care (preauthorization
required)
Blue Shield PPO
80-E $20, Rx 7-25
Member Pays
$300/$600
Blue Shield PPO
80-J $30, Rx 9-35
Member Pays
$750/$1,500
$1,000/$3,000
Blue Shield HDHP-HSA-B
OTHER SERVICES
PRESCRIPTION DRUG PLANS
Provider Network
Navitus
Navitus
Generic co-pay/days supply
$7 / 30-day
$9 / 30-day
Brand co-pay/days supply
$25 / 30-day
$35 / 30-day
$0 - $60 / 90-day
$0 - $90 / 90-day
$1,500 / $2,500
$2,500 / $3,500
Mail Order (Generic-Brand co-pay/days supply)
Prescription Drug Out-of-Pocket Maximum
Navitus
Navitus
Navitus
$5 / 30-day
$9 / 30-day
$9 / 30-day
$10 / 30-day
$35 / 30-day
$35 / 30-day
$0 - $20 / 90-day
$0 - $90 / 90-day
$0 - $90 / 90-day
$1,500 / $2,500
$2,500 / $3,500
$2,500 / $3,500
Note: This is a brief benefit summary that reflects in-network benefits from a participating or contracted provider. For additional details, limitations, exclusions and out-of-network coverage, please refer to the Summary of Benefits or Coverage Booklet. OOP Maximums on
these plans do not include the Navitus Pharmacy co-pays. Plans with a deductible all have 4th quarter deductible carryover (October 1-December 31) except for the HDHP-HSA plan. Co-pays and co-insurance do not carryover to the next calendar year. To find a
participating or contracting provider call the customer service number on your ID card or visit www.blueshieldca.com