Cabrillo Community College
SISC Blue Shield PPO Plans Comparison
Effective October 1, 2015
80-E $20, Rx 7-25
SC1083
SISC Plan Name
Group Number
HDHP-HSA Compatible-Plan B
SC1085
80-J $30, Rx 9-35
SC1084
$300 per individual up to $600 per family
$750 per individual up to $1,500 per family
$3,000 per individual up to $5,000 per family
$1,000 per individual up to $3,000 per family
$3,000 per individual up to $6,000 per family
$5,000 per individual up to $10,000 per family
This plan's Annual Out of Pocket Maximum
includes the member's deductible, co-pays
and 20% co-insurance.
This plan's Annual Out of Pocket Maximum
includes the member's deductible, co-pays
and 20% co-insurance.
This plan's Annual Out of Pocket Maximum
includes the member's deductible, co-pays and
10% co-insurance.
Participating
Providers
Deductible Waived,
$20 co-pay
Non-Participating
Providers
Participating
Providers
Deductible Waived,
$30 co-pay
Non-Participating
Providers
Participating
Providers
Non-Participating
Providers
50%
90% after deductible
50%
Inpatient Hospital
Room, Board & Support Services
(prior authorization required)
80%
$600 per day
80%
$600 per day
90%
$600 per day
Ambulatory Surgery Center
80%
$350 per day
80%
$350 per day
90%
Calendar Year Deductible(s)
Calendar Year Out of Pocket Maximum
Co-insurance is the member's responsibility to pay
when the plan is paying less than 100%
Out of Pocket is the maximum amount a member
will pay in a calendar year on eligible, in-network
charges
Services
Office Visits
Emergency Room (non-emergency)
Facility Expenses:
Professional Expenses:
Surgeon & Anesthetist
Accident Care (Professional)
(initial care)
$100 co-pay
Routine Exam
Diagnostic X-Ray & Lab
$100 co-pay
80%
50%
80%
50%
50%
80%
50%
80%
50%
80%
50%
90%
50%
80%
80%
80%
80%
90%
90%
Not Covered
Not Covered
80%
20 visits per year
80%
80%
Not Covered
Speech Therapy
Acupuncture
12 visits per year
Durable Medical Equipment
Hearing Aid ($700 maximum every 24 months)
Hospice
80%
Ambulance
Home Health Care
100 visits/yr (prior authorization required)
Psychiatric & Substance Abuse
Inpatient
80%
Chiropractic
Physical Medicine (PT, OT)
Outpatient Visits
Outpatient Prescription Drugs
Navitus Health Solutions
Supply
Generic Drugs
Single Source Brand Name Drugs
Multi Source Brand Drugs
$350 per day
$100 co-pay
80%
Deductible Waived,
100%
Deductible Waived,
100%
Preventative Care
50%
Deductible Waived,
100%
Deductible Waived,
100%
Not Covered
Not Covered
Not Covered
Not Covered
80%
20 visits per year
80%
80%
80%
50%
80%
50%
80%
50%
80%
50%
80%
80%
Not Covered
80%
Not Covered unless
pre authorized
80%
Not Covered unless
pre authorized
80%
80%
Not Covered
80%
Not Covered unless
pre authorized
80%
Not Covered unless
pre authorized
80%
Not Covered
80%
$600 per day
Deductible Waived,
50%
$20 co-pay
SISC Rx Plan 7-25
Navitus /Costco Mail
Retail
Costco Mail*
30 days
90 days
$7
$0
$25
$60
$7 + brand/generic
$21 + brand/generic
cost difference
cost difference
80%
80%
80%
Not Covered
Not Covered
80%
$600 per day
Deductible Waived,
50%
$30 co-pay
SISC Rx Plan 9-35
Navitus/Costco Mail
Retail
Costco Mail*
30 days
90 days
$9
$0
$35
$90
$9 + brand/generic
$27 + brand/generic
cost difference
cost difference
90%
Deductible Waived,
100%
Deductible Waived,
100%
50%
50%
Not Covered
Not Covered
90%
20 visits per year
90%
Not Covered
90%
Not Covered
90%
50%
90%
90%
90%
90%
90%
90%
Not Covered
50%
Not Covered
90%
Not Covered unless pre
authorized
90%
Not Covered unless pre
authorized
90%
$600 per day
90% after deductible
50%
Blue Shield Outpatient Prescription through
Blue Shield contracting providers
Retail
Mail
30 days
90 days
$7
$14
$25
$60
$25
$60
Brand Name Calendar Year Deductible
Not applicable
Not applicable
$3,000 medical deductible must be met
before co-pays apply.
Prescription Drug Out-of-Pocket Maximum
(individual/family)
$1,500/$2,500
$2,500/$3,500
Prescriptions are part of the medical and subject
to the medical Out-of-Pocket Maximum
* Eff 10/01/14, Members can get up to a 90-day supply through Costco Mail Order or at Costco Walk-in pharmacy with a 90-day prescription
from their doctor. Member's do not need a Costco Membership to use the pharmacy. Most generics will be at a $0 co-pay and brand name
drugs will be at the brand co-pay on their plan. If generic does not qualify for $0 co-pay program you will be charged three (3) times the
generic co-pay for a 90-day supply.
This plan does not have a prescription drug
carve out with Navitus and does not have the
the Costco Program. Copays apply after
medical deductible is paid.
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. Out-of-network benefits are paid at allowable amounts (a much lower payment) and subject to additional limits.
Patient will have greater out-of-pocket expenses when using a non-contracting provider. To find a participating or contracting provider call the customer service number on your ID card
or visit www.blueshieldca.com