Note - This short summary shows how	Blue Shield	Blue Shield
	benefits are paid when you use BS contracting	$500 Deductible	$750 Deductible
	providers. Non contracting providers are paid at 50%	PPO Plan	PPO Plan
	Annual Deductible	$500 (2 per family)	$750 (2 per family)
	Coinsurance Paid by Blue Shield	75% - Choice / 65% - Affiliated	70% - Choice / 60% - Affliated
	Your Coinsurance Percentage	25% - Choice / 35% - Affiliated	30% - Choice / 40% - Affiliated
	Your Maximum Out of Pocket Costs per Year	$3,500 single / $7,000 family	$4,000 single / $8,000 family
	using Preffered Providers
	Maximum Lifetime Benefit	$6,000,000	$6,000,000
	Pre-existing Condition/s waiting period	6 Months	6 Months
	(Credit is given on pre-existing condition/s waiting period if you have had prior health coverage)
	Office Visits	$30 CoPay -Choice / $40 CoPay - Affiliated	$35 CoPay -Choice / $45 CoPay - Affiliated
	Hospitalization - using a Choice Provider	25% after Ded.	30% after Ded.
	Hospitalization - using an Affiliated Provider	35% after Ded.	40% after Ded.
	Maternity - using a Choice Provider	$1000 + 25%	$1000 + 30%
	Maternity - using an Affiliated Provider	$1000 + 35%	$1000 + 40%
	Outpatient Surgery in Free Standing Surgi Center	25% after Ded.	30% after Ded.
	Laboratory & X-Ray	25% after Ded.	30% after Ded.
	Ambulance	25% after Ded.	30% after Ded.
	Emergency Room Visit	25% after Ded.	30% after Ded.
	Mental Health Services (inpatient & outpatient) are covered as any other illness for SEVERE conditions.
	Mental Health-Non Severe Outpatient visits	25% after Ded. (limit 20 visits/yr.)	30% after Ded. (limit 20 visits/yr.)
	Acupuncture	Not Covered	Not Covered
	Chiropractic Care (limited to 12 visits/yr)	Plan pays 50% up to $25 per visit - No Ded.	Plan pays 50% up to $25 per visit - No Ded.
	Allergy Testing / Treatment	25% - Choice / 35% - Affiliated (after Ded.)	30% - Choice / 40% - Affiliated (after Ded.)
	PREVENTIVE CARE
	Annual Routine Physical Exams	$30 CoPay - Choice / $40 - Affiliated	$35 CoPay - Choice / $45 - Affiliated
	Annual Gynecological Exam Office Visit	$30 CoPay - Choice / $40 - Affiliated	$35 CoPay - Choice / $45 - Affiliated
	Well-baby care office visits	$30 CoPay - Choice / $40 - Affiliated	$35 CoPay - Choice / $45 - Affiliated
	Immunizations	No Charge	No Charge
	Annual Pap Tests & routine Mammography	No Charge	No Charge
	Preventive Care Lab & X-Ray	25% after Ded.	30% after Ded.
	OUT PATIENT PRESCRIPTIONS
	Generic (30 day supply)	$7 CoPay	$10 CoPay
	Brand name (30 day supply)	$250 Ded, then $25 CoPay	$250 Ded, then $30 CoPay
	Mail Order (60 day supply)	$14 Generic / $50 Brand after $250 Ded.	$20 Generic / $60 Brand after $250 Ded.
	Non-formulary brand name drugs	$45 CoPay + 10% (max. of $100 per Rx)	$75 CoPay + 10% (max. $150 per Rx)
	NOTE: On the PPO, your Out of Pocket Costs are much higher when you use a Provider that does not contract with Blue Shield of California.
	For a more complete description of benefits, please refer to the Benefits Brochure.