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by Kim Fossen, Account Executive, Knight Insurance (Kim is one of the
benefits consultants who works with our Benefits Committee)
Glendale Community College has held a benefits
contract with Blue Shield of California since 1995.We would like to take
this opportunity to go over the plans currently offered by Blue Shield
and try to answer some questions you may have.
PPO BASICS:
The PPO option has a $200 deductible that must be
satisfied before any benefits are paid. The deductible is $400 if you
have dependents on the plan. Once the deductible is met, Blue Shield
will pay 90 percent if you use PPO-contracted physicians, laboratories
and hospitals. If you opt out to physicians that are not contracted,
Blue Shield will pay 70 percent of the amount that is allowed. This
means that you will be paying your 30 percent, plus any additional
amounts that are above what is considered reasonable and customary. You
should always ask if the doctor or facility is contracted with Blue
Shield PPO. Asking them if they "accept" Blue Shield is not
the same as being contracted with Blue Shield. There is a maximum
out-of-pocket amount for PPO ($1000 for individual/$2000 for family) and
non-PPO ($3000 for individual/$6000 for family). Once you hit these
amounts, Blue Shield will pay 100 percent of the charges.
BLUE SHIELD HMO FACTS:
The HMO option charges $5 for an office visit to your
primary care physician. All services must be done by the primary care
physician (PCP) or be referred by the PCP. If you are referred to a
specialist, always make sure you have referral paperwork from the doctor
and keep this paperwork for your records. Lab work, x-rays and
hospitalization are all covered at 100 percent when directed by the PCP.
If you receive a bill or statement from a laboratory or other facility,
please do not ignore it. Sometimes bills are not sent to the correct
place so they are not paid properly. Ultimately, the payment is your
responsibility, so you do not want to ignore bills that you receive. Our
benefits agent can help get things to the proper place but you need to
let her know what is happening.
DRUG FEES:
Both the HMO and PPO have a prescription drug card.
The co-payment for generic drugs is $5 and for brand-name drugs is $10.
If a generic drug is available and you choose to take the brand name,
you will pay your co-payment plus the difference in cost between the
generic and brand name drug. There is also a mail order benefit for any
maintenance drugs. The co-payment is $5 for generic or brand name for a
90-day supply.
The above is a brief outline of our plan with Blue
Shield. We encourage you to read your Blue Shield Evidence of Coverage
booklet for further details and clarification. If you have questions or
concerns, please contact Menchie Braza. She will be able to direct you
to the appropriate person for help. v |