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Blue Shield EPO

The  Blue Shield Exclusive Provider Organization (EPO) is a comprehensive medical plan that covers only in-network providers and facilities.

You pay a co-payment at the point of service and the university covers the remaining costs. If you choose to see a doctor or use a hospital outside the EPO's network, you pay the full cost of the care you receive. The EPO plan uses Blue Shield's nation-wide network of providers and hospitals.

View detailed information about the Blue Shield EPO

Basics  

Overview

You may visit any Blue Shield PPO network doctor or hospital.

For certain services or procedures, Blue Shield may require use of certain providers within their network.

There is no benefit if you see a Non-Network provider, except for emergency or urgent care.

Group #976109

Pre-Authorization Requirement

Pre-authorization required for all elective inpatient and outpatient procedures.

PENALTY for not pre-authorizing: benefit reduced to 50% of Blue Shield Allowed Amount. You pay balance of all charges not covered by Blue Shield. Out-of-Pocket Maximum does not apply.

Office copays

$20 copay primary/$50 copay specialist

 

Deductible

No deductible

Out-of-Pocket Maximum

$3,000 per individual / $6,000 per family

A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)
PREVENTATIVE CARE  

Physical exams for adults

100%

Physical exams for children

100%

Pap smears

100% (as part of the office visit)

Immunizations

100%

Travel immunizations not covered.
Well-woman visits 100%
PRESCRIPTION DRUGS  

Pharmacy (Retail)

Blue Shield Network pharmacy:
$10 generic; $30 brand name; $75 non-formulary -- up to a 30-day supply

Non-Network pharmacy: Member pays co-payment plus 25% of billed charges

Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime

Mail order drug program

$20 generic; $60 brand name; $150 non-formulary -- up to a 90-day supply

Must use Blue Shield mail-order service

Birth Control Pills

 Included in Prescription Drug benefit
 

Traveling Outside the U.S.

Benefits will be provided for covered services you receive anywhere within the Blue Shield network. Blue Shield has network providers outside of California and the United States. You can access service outside of California through the BlueCard Worldwide® Network.

If you need care while out of the country, call the toll-free BlueCard Program Access number at (800) 810-2583, or call collect at (804) 673-1177, 24 hours a day, seven days a week.

Before traveling abroad, call Blue Shield Customer Service at 800-873-3605 to find out what you need to make your plan work for you when you travel. For more information visit the Blue Shield’s website

In an emergency, go directly to the nearest hospital. As soon as possible, you should call Blue Shield at (800) 343-1691 or call collect at (804)673-1177, 24 hours a day, seven days a week.