Plan Details
Plan Name	Blue Shield PPO Super $aver/HSA Plan
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$3,200	$3,200
Annual Deductible/Family	$6,000	$6,000
Coinsurance	30%	50%
Office Visit/Exam	30%	50%
Outpatient Specialist Visit	30%	50%
Annual Out-of-Pocket Limit/Individual	$5,000	$10,000
Annual Out-of-Pocket Limit/Family	$10,000	$20,000
Preventive Care	0% ; deductible does not apply	50%
Inpatient Hospitalization	30%	50% subject to benefit maximum $600/day
Surgical Services Outpatient Facility Charge	30%	50% subject to a benefit maximum of $350/day
Emergency Room	30%	30%
Urgent Care Facility	30%	50%
Prescription Drug Deductible	combined with medical deductible	combined with medical deductible
Prescription Drugs - Generic	$10 Retail: /prescription	Not Covered
Prescription Drugs - Brand (Formulary/Preferred)	$30 Retail: /prescription	Not Covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50 Retail: /prescription	Not Covered
Prescription Drugs - Specialty	$100 Retail and Network Specialty Pharmacies: /prescription	Not Covered
Chiropractic Services	30% up to 20 visits per year	50% up to 20 visits per year
Acupuncture	Not covered	Not covered