What does the Blue Shield Gold 80 PPO health insurance plan cover?

What does the Blue Shield  Gold 80 PPO health insurance plan cover?

As an insurance agent, I am asked on a daily basis the following questions:

-how much do I have to pay when I see a doctor?

-how much do I have to pay when I go to the hospital?

-how much do I have to pay for medication? 

-how much is the blood test lab? 

oh, and so many more questions related to what the specific plan covers. In an attempt to help everyone understand their health insurance plan, I've summed up the benefits of health insurance plans. 

Let's start with the Blue Shield Gold 80 PPO plan:

Here is the summary of benefits for this plan for year 2016:

Calendar Year Medical Deductible -                          $0 (this plan does not have a deductible)
Calendar Year Out-of-Pocket Maximum-                  $6,200 per individual/ $12,400 per family

Many people are confused with this concept. So what is the out-of-pocket maximum? It is the sum of deductible, copayments and coinsurance for covered services from participating and non participating providers during the calendar year. In other words, the out-of-pocket maximum is everything that an individual has to pay out of pocket for related medical services that are specified by the plan but not covered by the insurance.

Covered Services:

Primary care physician office visit:                                                                                     $35
Specialist physician office visit:                                                                                            $55

Allergy Testing and Treatment Benefits:               
Primary care physician office visits (includes visits for allergy serum injections):  $35
Specialist physician office visits (includes visits for allergy serum injections):                    $55
Allergy serum purchased separately for treatment                                                                 20%

Preventative health services:                                                                                                $0
(As required by applicable Federal and California law, there is no copayment for preventive health services, including an annual preventive care or well-baby care office visit. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance.

CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital with prior authorization:                                           20%
Outpatient diagnostic x-ray and imaging performed in a hospital:                  $50
Outpatient diagnostic laboratory and pathology performed in a hospital        $35

Hospital Benefits:     

Outpatient surgery                                                                                                           20%
Outpatient visit:                                                                                                               20%

Outpatient services for treatment of illness or injury and necessary supplies      20%

Hospitalization Services

Inpatient physician fee                                                                                                20%

Inpatient non-emergency facility fee                                                                          20%
Bariatric surgery                                                                                                          20%
(For bariatric surgery- prior authorization is required and it is medically necessary surgery for weight loss for morbid obesity only. Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion.

Inpatient Skilled Nursing Benefits                                                                           20%

(combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Emergency Health Coverage

Emergency room visit not resulting in admission - facility fee                                                           $250

(copayment does not apply if the member is directly admitted to the hospital for inpatient services)

Emergency room visit resulting in admission -facility fee                                                      20%

(when the member is admitted directly from the ER)

Emergency room visit not resulting in admission - physician fee                                          20%
 (copayment does not apply if the member is directly admitted to the hospital for inpatient services)

Emergency room visit resulting in admission -physician fee                                                  20%

Urgent Care                                                                                                                           $60

Ambulance Services Emergency or authorized transport (ground or air)                      $250

PRESCRIPTION DRUG (PHARMACY COVERAGE)

Retail Pharmacies (up to a 30-day supply)
Mail Service Pharmacies (up to 90-day supply)

Contraceptive drugs and devices                                                                                $0

(Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment; and are not subject to the calendar year medical deductible. However, if a brand contraceptive drug is selected when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year medical or brand pharmacy deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copay)

Tier 1 Drugs:                                                   $15 per prescription
Tier 2 Drugs:                                                   $50 per prescription
Tier 3 Drugs:                                                   $70 per prescription
Tier 4 Drugs (excluding Specialty Drugs):     20% up to $250 maximum per prescription   

Home Health Services

Home health care agency visit:                       20%
(up to 100 prior authorized visits per calendar year)

Hospice Program Benefits:
Routine home care                                                                  no charge

Inpatient respite care                                                               no charge

24 hour continuous home care                                                            no charge

Short-term inpatient care for pain and symptom management no charge

Chiropractic Benefits:                                                          not covered

Acupuncture Benefits:                                                          $35

(Acupuncture services - benefits provided are for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain only)

Rehabilitation and Habilitation benefits:                            $35
(Physical, Occupational and Respiratory Therapy)

Speech Therapy Benefits                                                        $35

Pregnancy and Maternity Care benefits:                          
Prenatal and preconception physician office:                         $0

Family Planning Benefits:
Counseling and consulting                                                      $0
(includes insertion of IUD as well as injectable and implantable contraceptives for women)
Tubal ligation                                                                          $0

Vasectomy                                                                              20%

(an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

Infertility Services:                                                                not covered

Diabetes Care Benefits:

Devices, equipment, and non-testing supplies                                    20%
 (for testing supplies see Outpatient Prescription Drug Benefits)

Diabetes self-management training in an office setting                                  $35

Pediatric Vision Benefits: Pediatric vision benefits are available for members through the end of the month in which the member turns 19.

Pediatric Dental Benefits – Pediatric dental benefits are available for members through the end of the month in which the member turns 19.

 If you have questions about any of the above or would like to apply for health insurance, please feel free to contact us. We would be glad to provide free & confidential help! 

Here is how to reach us: 

by phone: 415-994-4121

web site: http://www.SFCheapInsurance.com 

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