Consumer Driven Health Plan with Health Savings Account Option
This plan has access to the BCBS Nationwide network which utilizes most of the major hospitals, pharmacies and many doctors as network providers. There is no out-of-network coverage with this plan. Effective July 1, 2011 there is an unlimited lifetime medical maximum. The co-payment for a primary care physician office visit is $25.00; specialist is $50.00. There is also a deductible for non-copayment services of $400.00 for employee only coverage, $800.00 employee plus one dependent, and $1,200.00 for 3 or more family members. You may self-refer to a specialist on the provider listing. Hospital co-payment is $100.00 per day with a maximum of 3 days co-payment. See prescription drug information below. More information, including a list of Blue Cross providers is available on Group Benefits website: www.groupbenefits.org or https://www.bcbsla.com/ogb
The prescription benefits for these plans are administered by Med Impact. The member pays 50%; maximum $50 per 30-day fill; and after $1500 per person per plan year, the co-pay is $0 for generic $15 for brand. NOTE: The pharmacy benefits are mandatory generics. Plan member who chooses brand name drug for which approved generic version is available pays cost difference between brand name drug and generic drug, plus 50% co-pay amount for brand name drug; cost difference does not apply to $1500 out-of-pocket maximum. You can contact MedImpact at 800-910-1831.