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Home My WebLink AboutBlue Shield Choosing Your Planhow to choose the health plan that’s right for you It’s easy to feel a little confused about where to start when choosing a health plan. Some people ask their friends, family, or co-workers for advice. Knowing the right questions to ask can help you make an informed decision and find the right plan for you and your family. 1 2 3 In this guide you will find helpful information on how you can compare health plans to help you make the right choice, including: Questions to consider Cost comparison chart Glossary of common terms used to describe benefits of HMO, PPO, and POS plans Questions to consider plan A plan B NAme of PlAN Are the doctors, hospitals, laboratories, and other healthcare providers that you or your family uses in the health benefit provider’s network? Are you or your family members allowed to see a doctor outside the network? If so, what is the reimbursement difference? Does this plan require that you or your family members get a referral in order to see a specialist? Does the health plan offer coverage for you or your family members who live outside of California (for college or work)? Do you or your family members have a chronic condition such as asthma, cancer, or diabetes? If so, does the health plan offer any special services or programs for these conditions? Does the plan cover the prescription medicines that you or your family members use? Does the plan reimburse alternative medical therapies such as acupuncture or chiropractic treatment? Does the plan cover the costs of delivering a baby? Does the plan cover mental health and/or substance abuse? Are there specific services or treatments you would like covered? Consider these questions when comparing plan options. Check or enter information in the boxes below for the plans you are comparing. plan A plan B NAme of PlAN Type of plan (HMO, PPO, etc.) Premiums (this is the amount that comes out of your paycheck biweekly/monthly, etc.) meDICAl BeNefIts Annual out-of-pocket maximum or copayment maximum Annual deductible Physician office visits Specialist office visits Outpatient X-ray, pathology, lab work Pregnancy and maternity care benefits Emergency room services Outpatient surgery performed by an ambulatory surgery center Outpatient surgery performed in a hospital Compare the costs plan A plan B Inpatient non-emergency facility services Family planning and infertility benefits Chiropractic services Rehabilitation benefits (physical, occupational, and respiratory therapy) Mental health services Substance abuse services Other: PhArmACy BeNefIts Annual deductible Formulary generic drugs Formulary brand-name drugs Non-formulary brand-name drugs Specialty drugs to help you compare health plans, enter the amounts for copayments, coinsurance, etc. below for the plans you are considering. You may have different deductibles, copayments, or coinsurance for network or non-network providers. Choose the deductibles, copayments, or coinsurance for the providers you think you will use the most. Also, check the plan’s website to see if any prescriptions you or your dependents are taking are in the plan’s formulary. If the plan offers a mail-service pharmacy, you may be able to save money on maintenance medications. Brand-name drugs: FDA-approved drugs under patent to the original manufacturer and available only under the original manufacturer’s branded name. Calendar year: A period beginning at 12:01 a.m. on January 1 and ending at 12:01 a.m. of the next year. Claim: A notification to your health plan that a service has been provided and payment is requested. Copayment: The dollar amount that a member is required to pay for certain benefits. Also called a “copay.” emergency services: Services for an unexpected medical condition, including a psychiatric emergency medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a layperson who possesses an average knowledge of health and medicine could reasonably assume that the absence of immediate medical attention could be expected to result in any of the following: placing the member’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. formulary: A comprehensive list of drugs maintained by Blue Shield’s Pharmacy and Therapeutics Committee for use under the Blue Shield Prescription Drug Program, which is designed to assist physicians in prescribing drugs that are medically necessary and cost effective. The formulary is updated periodically. If not otherwise excluded, the formulary includes all generic drugs. Generic drugs: Drugs that (1) are approved by the FDA as a therapeutic equivalent to the brand-name drug, (2) contain the same active ingredient as the brand-name drug, and (3) cost less than the brand-name drug equivalent. health maintenance organization (hmo): A prepaid health plan that provides a comprehensive array of medical services, emphasizing prevention and early detection through contracted physicians, hospitals, and other providers. Members must select a primary care physician from the plan’s network who coordinates all care with the exception of medical emergencies. Inpatient: An individual who has been admitted to a hospital as a registered bed patient, and is receiving services under the direction of a physician. Glossary Non-formulary drugs: Drugs determined by the health plan as being duplicative or as having preferred formulary drug alternatives available. Benefits may be provided for non-formulary drugs and are always subject to the non-formulary copayment. outpatient: An individual receiving services but not as an inpatient. out-of-pocket maximum: Your maximum copayment responsibility each calendar year for covered services. However, copayments for a very small number of covered services do not apply to the annual out-of-pocket maximum, and you continue to be responsible for copayments for those services when the out-of-pocket maximum is reached. Personal Physician (also known as a primary care physician): A general practitioner, board- certified or -eligible family practitioner, internist, obstetrician/ gynecologist, or pediatrician who has contracted with the plan as a personal physician to provide primary care to members and to refer, authorize, supervise, and coordinate the provision of all benefits to members in accordance with the agreement. Preferred provider organization (PPo): A PPO is similar to a traditional “fee-for-service” plan, but you must use doctors in the PPO provider network or pay a higher coinsurance (percentage of charges). A PPO allows you to select a primary care provider and specialists without referral. In these plans, you typically must meet an annual deductible before some benefits apply. You are responsible for a certain coinsurance amount and the plan pays the balance up to the allowable amount. As a PPO health plan member, you get maximum benefit coverage when you use the PPO network of physicians and hospitals. Preventive care: Medical services provided by a physician for the early detection of disease when no symptoms are present and for routine physical examinations, usually limited to one visit per calendar year for members age 18 and over. services: Includes medically necessary healthcare services and medically necessary supplies furnished incident to those services. Not sure what it means? You can use this glossary as a handy reference to some common health benefit terms. Now take the next step Choose the right coverage for you and your family. blueshieldca.com Blue Shield of California is an Independent Member of the Blue Shield Association A37809-LPS (8/11)