Plan summary

Lifetime maximum
This is the limit to the amount of money Blue Shield will pay for covered services throughout your entire life while you are covered under your health plan. Check your Evidence of Coverage/Certificate of Insurance to see if your specific plan or policy has a lifetime maximum.

Deductible
This is the first amount you must pay for some services in your plan before you can get certain benefits.

You may have two kinds of deductibles: medical and pharmacy. Your medical deductible covers services in your plan such as physician office visits. Your pharmacy deductible applies to outpatient drugs from a provider in our network. For more information about your plan's deductible, please look at your Evidence of Coverage/Certificate of Insurance.

Copayment maximum
This is the limit to the amount of money you will be required to pay in a year for certain services. The copayments you make for most services go toward this copayment maximum.

Primary care physician
For our Blue Shield HMO and POS members, their primary care physician is the doctor who handles their medical care.

As soon as you become a member, you must choose a primary care physician. This physician is usually your first contact for healthcare and will treat most of your health problems and arrange your health plan benefits. If needed, he or she will also refer you to a specialist.

Rx-brand
This is a drug produced and sold under the brand name of the original maker.

If you choose a brand-name drug that is available in generic form, you will probably pay the difference between Blue Shield's cost for the brand-name drug and the cost of the generic drug (as well as any copays you may have).

If you see a copay range, your pharmacist will figure out your copayment as follows:

Your cost = copay amount + [(cost of the drug - copay) times a percentage of the difference].

For example, if the total cost of the drug is $300 with a copay of $45, you would calculate a 10% difference like this:

• $300-$45 equals $255
• 10% of $255 is $25.50 
• Add up the $45 copay with the 10% charge of $25.50 and you get $70.50.
  Therefore, your total copay will be $70.50.

Generic drugs are almost always cheaper than brand-name drugs.

Rx-generic
These are drugs that are the same as – and almost always cheaper than – brand-name drugs. If you see a copay range, your pharmacist will figure out your copayment as follows:

Your cost = copay amount + [(cost of the drug - copay) times a percentage of the difference].

For example, if the total cost of the drug is $300 with a copay of $45, you would calculate a 10% difference like this:

• $300-$45 equals $255
• 10% of $255 is $25.50 
• Add up the $45 copay with the 10% charge of $25.50 and you get $70.50 
  Therefore, your total copay will be $70.50.

Rx-non-formulary
This is medication that has a cheaper version listed in our drug formulary (a formulary is a list of medications covered in a plan).

Some plans do not offer benefits for drugs that are not listed on the formulary (plans that do offer benefits for drugs that are not on the formulary may have a higher copay).

If you see a copay range, your pharmacist will figure out your copayment as follows:

Your cost = copay amount + [(cost of the drug - copay) times a percentage of the difference].

For example, if the total cost of the drug is $300 with a copay of $45, you would calculate a 10% difference like this:

• $300-$45 equals $255
• 10% of $255 is $25.50
• Add up the $45 copay with the 10% charge of $25.50 and you get $70.50 
  Therefore, your total copay will be $70.50.

Self-referred office visit
For our HMO and POS members, this benefit allows you to go directly to a specialist in your primary care physician's medical group or IPA (Individual Physician Association) without a referral.