Plan summary

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 by 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.

Help with copays
A copay (or coinsurance) is a cost sharing setup in which a member of Blue Shield pays a dollar amount or a percentage of the cost, or a combination of both, for a specific medical service. For example, $20 for an office visit or 30% for surgical procedures.

Copays vary by plan type and services. Look at your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for specific details.

An EOC or COI was sent to you when you first joined Blue Shield. If you need another copy:

• Go to your Plan Summary page and download a copy or ask that a copy be mailed to you (not available to all members).
• Contact your Human Resource department for a copy if you have health care through your company.
• Call the Member Services number on your Blue Shield ID card and ask that a copy be mailed to you.