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Participating Providers1 Participating Providers1 Non Participating Providers2 Participating Providers1 Non Participating Providers2 Participating Providers1 Participating Providers1 Non Participating Providers2 Participating Providers1 Non Participating Providers2 $20 per visit (not subject to the Calendar Year medical deductible) $20 per visit (not subject to the Calendar Year medical deductible) 50% $30 per visit (not subject to the Calendar Year medical deductible) 50% $20 per consultation (not subject to the Calendar Year medical deductible) $20 per consultation (not subject to the Calendar Year medical deductible) Not Covered $30 per consultation (not subject to the Calendar Year medical deductible) Not Covered No Charge (not subject to the Calendar Year medical deductible) No Charge (not subject to the Calendar Year medical deductible) 50% No Charge (not subject to the Calendar Year medical deductible) 50% 10% 20% 50% 20% 50% No Charge (not subject to the Calendar Year medical deductible) No Charge (not subject to the Calendar Year medical deductible) Not Covered No Charge (not subject to the Calendar Year medical deductible) Not Covered Home Delivery Home Delivery Retail Home Delivery Retail $10.00 $10.00 $5.00 $20.00 $10.00 $75.00 $75.00 $30.00 $40.00 $20.00 $112.50 $112.50 $45.00 $90.00 $45.00 30% with $300 copay max 30% with $300 copay max 30% with $150 copay max 30% with $300 copay max 30% with $150 copay max None None None EIAHealth/Small Group Program ASO PPO Plans Platinum/Gold/Silver Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: January 1, 2020 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Platinum Plan Gold Plan Silver Plan Non Participating Providers2 Calendar Year Medical Deductible (All providers combined, 4th quarter carryover applies) $300 per individual / $600 per family $500 per individual / $1,000 per family $2000 per individual / $4,000 per family Calendar Year Out-of-Pocket Maximum (All providers combined accumulate towards the Calendar Year out-of-pocket maximum amount.) $1,300 per individual / $3,600 per family $2,000 per individual / $4,000 per family $5,000 per individual / $10,000 per family Lifetime Benefit Maximum None None None OUTPATIENT PROFESSIONAL SERVICES Non Participating Providers2 Professional (Physician) Benefits Physician and specialist office visits 50% Teladoc consultation Not Covered Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services 50% Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) 50% Preventive Health Benefits11 Preventive health services (as required by applicable Federal law) Not Covered Prescription Benefits Retail Generics $5.00 Preferred Brands $30.00 Non Preferred Brands $45.00 Specialty Drugs 30% with $150 copay max Deductible None $200/$500 applies to brand name drugs only Out of Pocket Maximum $5,300/$9,600 $4,600/$9,200 $1,600/$3,200