Cabrillo College
BLUE SHIELD HMO (SISC) - MEDICAL PLAN OPTIONS
Effective October 1, 2016
HMO $10-0 w/Chiro
Current / Renewal
HMO $20-250 w/Chiro
Proposed Option
HMO $25-500 w/Chiro
Current / Renewal
HMO $30-20%
Zero Facility w/Chiro
Proposed Option
HMO $30-20%
Zero Facility w/Chiro
Current / Renewal
HMO $30-20% - SaveNet
Zero Facility w/Chiro
Proposed Option
None
$1,000 / $2,000
Calendar Year Copayment Maximum
None
$1,500 / $3,000
Calendar Year Copayment Maximum
None
$2,000 / $4,000
Calendar Year Copayment Maximum
None
$1,500 / $3,000
Calendar Year Copayment Maximum
None
$1,500 / $3,000
Calendar Year Copayment Maximum
None
$1,500 / $3,000
Calendar Year Copayment Maximum
$10
$10 referral / $30 Access+ self-referral
No charge
$10
No charge
No charge
$10 / 30 visits (combined)
$20
$20
No charge
$20
No charge
No charge
$20 / 30 visits (combined)
$30
$30 referral / $45 Access+ self-referral
$0
$30
20% up to $1,500 p/member
No charge
$10 / 30 visits (combined)
$30
$30 referral / $45 Access+ self-referral
$0
$30
20% up to $1,500 p/member
No charge
$10 / 30 visits (combined)
$30
$30 referral / $45 Access+ self-referral
$0
$30
20% up to $1,500 p/member
No charge
$10 / 30 visits (combined)
Outpatient Surgery
No charge
No charge
No charge
No charge
No charge
Emergency Room
Mental Health Care/Substance Abuse
Inpatient Hospital Facility
Outpatient Physician Visit
Outpatient Prescription Drugs
Showing In-Network Benefits Only
Rx Out of Pocket Maximum (Ind / Fam)
(At participating Pharmacies only)
Retail - 30 day supply
Mail order - 90 day supply
Annual Deductible
$100
No charge
No charge
$10
$100
$250 / Admit
$250 / Admit
$20
$25
$25 referral / $30 Access+ self-referral
$0
$25
$500 / Admit
No charge
$10 / 30 visits (combined)
$150 at an Ambulatory Surgery Center;
$300 at a Hospital
$100
$500 / Admit
$500 / Admit
$25 per visit
$150
20% up to $1,500 p/member
20% up to $1,500 p/member
$30 per visit
$150
20% up to $1,500 p/member
20% up to $1,500 p/member
$30 per visit
$150
20% up to $1,500 p/member
20% up to $1,500 p/member
$30 per visit
Benefits
Calendar Year Deductible (Individual / Family)
Out-of-Pocket Maximum
Individual / Family
MAJOR MEDICAL
Physician Office Visit
Specialist Visit
Preventive Care
Urgent Care
Inpatient Hospital
Lab & X-Ray
Chiropractic / Acupuncture
Navitus (Retail)
Actives
Costco
Navitus (Retail)
Costco
Navitus (Retail)
Costco
Navitus (Retail)
Costco
Navitus (Retail)
Costco
Navitus (Retail)
Costco
$1,500 / $2,500
Generic/Brand
$1,500 / $2,500
Generic/Brand
$2,500 / $3,500
Generic/Brand
$2,500 / $3,500
Generic/Brand
$2,500 / $3,500
Generic/Brand
$2,500 / $3,500
Generic/Brand
$5/$10
$0/$10
$0/$20 (Costco Mail Order)
N/A
$5/$20
$0/$20
$0/$50 (Costco Mail Order)
N/A
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
N/A
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
N/A
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
N/A
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
N/A
2015-2016
2016-2017
Proposed Option
2015-2016
2016-2017
Proposed Option
2015-2016
2016-2017
Employee Only
13
$980
$982
$879
101
$792
$813
$762
40
$742
$762
$735
Employee + 1
13
$1,900
$1,902
$1,718
51
$1,554
$1,594
$1,492
7
$1,453
$1,492
$1,437
Family
11
$2,653
$2,654
$2,411
90
$2,186
$2,243
$2,097
28
$2,043
$2,097
$2,019
Total Monthly Premium
37
$66,623
$66,686
$60,282
242
$355,986
$365,277
$341,784
75
$97,055
$99,640
$95,991
$799,476
$800,232
$723,384
$4,271,832
$4,383,324
$4,101,408
$1,164,660
$1,195,680
$1,151,892
Total Annual Premium
Proposed Option
$ ∆ to Current
$756
-$76,848
$111,492
-$281,916
$31,020
-$43,788
% ∆ to Current
0.1%
-9.6%
2.6%
-6.4%
2.7%
-3.7%
Early Retiree
Employee Only
Employee + 1
Family
Total Monthly Premium
Total Annual Premium
4
5
2
11
2015-2016
2016-2017
Proposed Option
$980
$1,900
$2,653
$18,726
$224,712
$982
$1,902
$2,654
$18,746
$224,952
$879
$1,718
$2,411
$16,928
$203,136
$ ∆ to Current
% ∆ to Current
$240
0.1%
Retirees Over Age 65
Retiree
Retiree plus 1 dependent
8
Total Monthly Premium
Total Annual Premium
8
$ ∆ to Current
% ∆ to Current
0
10
4
0
14
2016-2017
Proposed Option
$792
$1,554
$2,186
$14,136
$169,632
$813
$1,594
$2,243
$14,506
$174,072
$762
$1,492
$2,097
$13,588
$163,056
-$21,816
-9.7%
$4,440
2.6%
2015-2016
2016-2017
Proposed Option
$674
$1,348
$723
$1,446
$579
$1,158
8
$5,392
$64,704
$5,784
$69,408
$4,632
$55,584
8
$4,704
7.3%
2015-2016
0
-$13,824
-19.9%
0
1
0
1
2015-2016
2016-2017
Proposed Option
$742
$1,453
$2,043
$1,453
$17,436
$762
$1,492
$2,097
$1,492
$17,904
$735
$1,437
$2,019
$1,437
$17,244
-$11,016
-6.3%
2015-2016
2016-2017
Proposed Option
$462
$924
$511
$1,022
$509
$1,018
$3,696
$44,352
$4,088
$49,056
$4,072
$48,864
$4,704
10.6%
Note: This summary is for informational purpose only. It does not amend, extend, or alter the current policy in any way. In the event information in this summary differs from the Plan Document, the Plan Document will prevail.
$468
2.7%
0
0
0
-$192
-0.4%
-$660
-3.7%
2015-2016
2016-2017
Proposed Option
$460
$920
$509
$1,018
$509
$1,018
$0
$0
$0
$0
$0
$0
$0
0.0%
$0
0.0%
Cabrillo College
BLUE SHIELD PPO (SISC) - MEDICAL PLAN OPTIONS
Effective October 1, 2016
PPO 80-E
Current / Renewal
PPO 80-G
Proposed Option
PPO 80-J
Current / Renewal
PPO 80-K
Proposed Option
$300 / $600
$1,000 / $3,000
Calendar Year Out-of-Pocket Max
In Network
Out of Network
Ded waived; $20
50%
Ded waived; $20
50%
Ded waived; 100%
Not Covered
Ded waived; $20
50%
80%
$600 p/day
80%
Not Covered
Not Covered
80% 1
$500 / $1,000
$2,000 / $4,000
Calendar Year Out-of-Pocket Max
In Network
Out of Network
Ded waived; $20
50%
Ded waived; $20
50%
Ded waived; 100%
Not Covered
Ded waived; $20
50%
80%
$600 p/day
80%
Not Covered
Not Covered
80% 1
$750 / $1,500
$3,000 p/ind; $6,000 per fam
Calendar Year Out-of-Pocket Max
In Network
Out of Network
Ded waived; $30
50%
Ded waived; $30
50%
Ded waived; 100%
Not Covered
Ded waived; $30
50%
80%
$600 p/day
80%
Not Covered
Not Covered
80% 1
$1,000 / $2,000
$3,000 p/ind; $6,000 per fam
Calendar Year Out-of-Pocket Max
In Network
Out of Network
Ded waived; $30
50%
Ded waived; $30
50%
Ded waived; 100%
Not Covered
Ded waived; $30
50%
80%
$600 p/day
80%
Not Covered
Not Covered
80% 1
Benefits
Calendar Year Deductible (Individual / Family)
Out-of-Pocket Maximum
Individual / Family
MAJOR MEDICAL
Physician Office Visit
Specialist Visit
Preventive Care
Urgent Care
Inpatient Hospital
Lab & X-Ray
Chiropractic / Acupuncture
Outpatient Surgery
80%
$350 p/day 2
$100 per visit + 20% (waived if admitted)
Ded waived; $20
50%
80%
$600 p/day
Ded waived; $20
50%
Emergency Room
Mental Health Care/Substance Abuse
Inpatient Hospital Facility
Outpatient Physician Visit
Outpatient Prescription Drugs
Showing In-Network Benefits Only
Rx Out of Pocket Maximum (Ind / Fam)
(At participating Pharmacies only)
Retail - 30 day supply
Mail order - 90 day supply
Annual Deductible
Navitus (Retail)
Costco
$1,500 / $2,500 (In-network Only)
Generic/Brand
$7/$25
$0/$25
$0/$60 (Costco Mail Order)
$300 p/ind; $600 p/fam
Actives
$350 p/day 2
80%
80%
$100 per visit + 20% (waived if admitted)
80%
50%
80%
$600 p/day
80%
50%
Navitus (Retail)
Costco
$1,500 / $2,500 (In-network Only)
Generic/Brand
$7/$25
$0/$25
$0/$60 (Costco Mail Order)
$300 p/ind; $600 p/fam
$350 p/day 2
PPO HDHP -B w/HSA Compatibility
Current / Renewal
$3,000 / $5,200
$5,000 p/ind or $10,000 per fam
Calendar Year Out-of-Pocket Max
In Network
Out of Network
90%
50%
90%
50%
Ded waived; 100%
Not Covered
90%
50%
90%
$600 p/day
90%
Not Covered
Not Covered
90% 1
$350 p/day 2
80%
90%
$350 p/day 2
$100 per visit + 20% (waived if admitted)
Ded waived; $30
50%
80%
$600 p/day
Ded waived; $30
50%
$100 per visit + 20% (waived if admitted)
Ded waived; $30
50%
80%
$600 p/day
Ded waived; $30
50%
$100 per visit + 10% (waived if admitted)
90%
50%
90%
$600 p/day
90%
50%
Navitus (Retail)
Navitus (Retail)
Rx w/ Blue Shield Contracted Provider
Costco
$2,500 / $3,500 (In-network Only)
Generic/Brand
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
$750 p/ind; $1,500 p/fam
Costco
$2,500 / $3,500 (In-network Only)
Generic/Brand
$9/$35
$0/$35
$0/$90 (Costco Mail Order)
$750 p/ind; $1,500 p/fam
Combined with Medical OOP Maximum
Generic/Brand
$9/$35 after the deductible
$18/$90 (Blue Shield Mail Order)after the deductible
$3,000 medical deductible must be met
2015-2016
2016-2017
Proposed Option
2015-2016
2016-2017
Proposed Option
Employee Only
27
$968
$971
$915
14
$861
$864
$852
23
$701
$734
Employee + 1
15
$1,807
$1,814
$1,707
10
$1,607
$1,614
$1,591
4
$1,323
$1,389
Family
10
$2,679
$2,681
$2,521
13
$2,382
$2,387
$2,353
4
$1,998
$2,093
Total Monthly Premium
52
$80,031
$80,237
$75,520
37
$59,090
$59,267
$58,427
31
$29,407
$30,810
$960,372
$962,844
$906,240
$709,080
$711,204
$701,124
$352,884
$369,720
Total Annual Premium
2015-2016
2016-2017
$ ∆ to Current
$2,472
-$56,604
$2,124
-$10,080
$16,836
% ∆ to Current
0.3%
-5.9%
0.3%
-1.4%
4.8%
Early Retiree
Employee Only
Employee + 1
Family
Total Monthly Premium
Total Annual Premium
19
16
0
35
2015-2016
2016-2017
Proposed Option
$968
$1,807
$2,679
$47,304
$567,648
$971
$1,814
$2,681
$47,473
$569,676
$915
$1,707
$2,521
$44,697
$536,364
$ ∆ to Current
% ∆ to Current
$2,028
0.4%
Retirees Over Age 65
Retiree
Retiree plus 1 dependent
37
Total Monthly Premium
Total Annual Premium
40
3
2
1
0
3
Proposed Option
$864
$1,614
$2,387
$3,342
$40,104
$852
$1,591
$2,353
$3,295
$39,540
$156
0.4%
2016-2017
Proposed Option
$531
$1,062
$580
$1,160
$576
$1,152
5
$22,833
$273,996
$24,940
$299,280
$24,768
$297,216
5
$25,284
9.2%
2016-2017
$861
$1,607
$2,382
$3,329
$39,948
-$33,312
-5.8%
2015-2016
$ ∆ to Current
% ∆ to Current
2015-2016
0
-$2,064
-0.7%
2
Chiropractic limited to 20 visits per calendar year, Acupuncture limited to 12 visits per calendar year
Performed at an ambulatory surgery center
0
0
1
2016-2017
$701
$1,323
$1,998
$701
$8,412
$734
$1,389
$2,093
$734
$8,808
$396
4.7%
2016-2017
Proposed Option
$485
$970
$534
$1,068
$568
$1,136
0
$2,425
$29,100
$2,670
$32,040
$2,840
$34,080
0
$2,940
10.1%
2015-2016
-$564
-1.4%
2015-2016
Note: This summary is for informational purpose only. It does not amend, extend, or alter the current policy in any way. In the event information in this summary differs from the Plan Document, the Plan Document will prevail.
1
1
0
$2,040
6.4%
2015-2016
2016-2017
$485
$970
$496
$992
$0
$0
$0
$0
$0
0.0%