Cabrillo Community College
Blue Shield HMO Plan Comparison
Effective October 1, 2015
$10-0 HMO Plan
Rx $5-10
$25 - 500 w/Chiro HMO Plan
Rx $9-35
$30 - 20% Zero Facility Ded Plan
Rx $9-35
HSC217
HSC218
HSC238, HSC239, HSC240
NONE
NONE
NONE
$1,000 / $2,000
$2,000 / $4,000
$1,500 / $3,000
$10
$10/$30*1
$0
$25
$25/$30*1
$0
$30
$30/$45*1
$0
Lab and X-Ray
No Charge
No Charge
No Charge
Outpatient Surgery
No Charge
$150 at an Ambulatory Surgery Center
$300 at a Hospital
No Charge
No Charge
$100
$100
(waived if admitted)
20% of allowed charges
once every 24 months
$10 in your service area
$50 outside your service area
$10 (up to 30 visits conbined with
Acupuncture per cal year)1
$500 / Admit
$100
$100
(waived if admitted)
20% of allowed charges
once every 24 months
$25 in your service area
$50 outside your service area
$10 (up to 30 visits conbined with
Acupuncture per cal year)1
20%
$100
$150
(waived if admitted)
20% of allowed charges
once every 24 months
$30 in your service area
$50 outside your service area
$10 (up to 30 visits conbined with
Acupuncture per cal year)1
No Charge
$100 per day
20%
$10 (up to 100 visits per cal year)
$25 (up to 100 visits per cal year)
$30 (up to 100 visits per cal year)
No Charge
$10
$500 / Admit
$25
20%
$30
No Charge
No Charge
$500 / Admit
$500 / Admit
20%
20%
$10
$25
$30
SISC HMO Plan Name
Group Number
Calendar Year Deductible
Individual / Family
Calendar Year Out-of-Pocket Maximum
Individual / Family
MAJOR MEDICAL
Physician Office Visit
Specialist Visit
Preventive Care
Hospitalization
Inpatient
Ambulance
Emergency Room
Durable Medical Equipment
Urgent Care
Chiropractic Service/Acupuncture
(services through ASH)
Skilled Nursing (Up to 100 days/cal year)
Home Health Care
Mental Health
Inpatient hospital facility
Outpatient Pysician Visit
Substance Abuse - (see separate rider)
Inpatient Detox
Inpatient hospital facility
Outpatient Physican Visit
Outpatient Prescription Drugs
Navitus Health Solutions
Supply
Generic Drugs
Single Source Brand Name Drugs
Multi Source Brand Drugs
Brand Name Calendar Year Deductible
SISC Rx Plan 5-10
Navitus /Costco Mail
Retail
Costco Mail**
30 days
90 days
SISC Rx Plan 9-35
Navitus/Costco Mail
Retail
Costco Mail**
30 days
90 days
SISC Rx Plan 9-35
Navitus/Costco Mail
Retail
Costco Mail**
30 days
90 days
$5
$0
$9
$0
$9
$0
$10
$20
$35
$90
$35
$90
$5 + brand/generic cost $15 + brand/generic
difference
cost difference
Not applicable
$9 + brand/generic $27 + brand/generic
cost difference
cost difference
Not applicable
$9 + brand/generic $27 + brand/generic
cost difference
cost difference
Not applicable
* Access + Specialist (self-referred office visits within your medical group are available for higher copay)
1
These member payments do not apply to the member calendar year Copayment 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 copay program you will be charged three (3) times the generic co-pay for a 90-day supply.
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. There is no coveage for out-of-network services unless emergency or urgent care is needed. Members
enrolled on an HMO plan must elect a Primary Care Physician (PCP) and include their provider number on your enrollment form. To find a participating or contracting provider call the
customer service number on your ID card or visit www.blueshieldca.com