2025-2026 Blue Shield & PCPs Plan Comparison

	A	B	C	D	G	J
1	Plan Type (PPO or HMO)	PPO	PPO	PPO	PPO	PPO
2	Carrier (Anthem Blue Cross, Blue Shield, or Kaiser)	Blue Shield	Blue Shield	Blue Shield	Blue Shield	Anthem
3	District Name
4	Bargaining Unit					NEW! Preventive Care Plans (PCP)
5	2025-2026	Blue Shield	Blue Shield	Blue Shield	Blue Shield	Anthem
6		100-B $20	90-E $20 (Non-Marketed)	80-G $30 (Non-Marketed)	HSA $3,400	Platinum+
7
8	MEDICAL - CALENDAR YEAR Deductibles & Maximums	Member Pays	Member Pays	Member Pays	Member Pays	Member Pays
9	Individual/Family Deductibles (Ded)	$100/$300	$300/$600	$500/$1,000	$3,400/$6,800*	$0/$0
10	Individual/Family Out-of-Pocket (OOP) Max (includes medical deductibles, co-insurance and co-pays)	$1,000/$3,000	$1,000/$3,000	$2,000/$4,000	$6,000/$12,000*	$1,000/$3,000
11					*Includes Rx
12	PROFESSIONAL SERVICES
13	Primary Care* visit co-pay ($0 Copay for 1st 3 cal yr Primary Care OV on Non-HSA PPO plans)	$20	$20	$30	Deductible, then 10% after Ded	$0
14	Urgent Care co-pay	$20	$20	$30	10% after Ded	$0
15	Prenatal, postnatal office visit co-pay	$20	$20	$30	10% after Ded	$0
16	Specialists/Consultants co-pay	$20	$20	$30	10% after Ded	$40
17						Non-Hosp/OPH**
18	Scans: CT, CAT, MRI, PET etc.	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$100/$250
19	Laboratory Procedures	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0/$50
20	Diagnostic X-rays	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$25/$75
21	Infertility (Refer to Plan Document)	Not covered	Not covered	Not covered	Not covered	Not covered
22	Preventive Care (includes physical exams & screenings)	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	0% after Ded Ded Waived	$0
23
24	HOSPITAL & SKILLED NURSING FACILITY SERVICES
25	Emergency Room visit (copay waived if admitted) - Avg Cost: $2,847 \| $100+10%: $375 \| $100+20%: $649	0% after Ded $100 co-pay	10% after Ded $100 co-pay	20% after Ded $100 co-pay	10% after Ded $100 co-pay	$300
26	Inpatient Hospital (preauthorization required) - Avg Cost for one day: $6,067 \| 10%: $607 \| 20%: $1,213	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$200/day
27	Surgery, Outpatient (performed in Surgery Center)	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$200
28	Surgery, Outpatient (performed in a Hospital) - limits may apply	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$600
29
30	MENTAL HEALTH & SUBSTANCE ABUSE TREATMENT
31	INPATIENT: Facility Based Care (preauth required)	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$200/day
32	OUTPATIENT: Facility Based Care (preauth required)	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0
33
34	OTHER SERVICES
35	Ambulance (Ground or Air)	0% after Ded $100 co-pay	10% after Ded $100 co-pay	20% after Ded $100 co-pay	10% after Ded $100 co-pay	$300
36	Acupuncture - Limits apply	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0
37	Chiropractic - Limits apply	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0
38	Physical and Occupational Therapy - Limits apply	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0
39	Durable Medical Equipment (DME)	0% after Ded	10% after Ded	20% after Ded	10% after Ded	$0
40	Hearing Aids	Amount in excess of $700 allowance/24 months	10% after Ded and Amount in excess of $700 allowance/24 months	20% after Ded and Amount in excess of $700 allowance/24 months	10% after Ded and Amount in excess of $700 allowance/24 months	$0 plus the amount in excess of $700 allowance/24 months
41	*Primary Care Providers (PCPs) are those without specialty certifications, practicing general pediatrics, internal medicine, family or general practice, or obstetrics and gynecology.
42
43	PHARMACY BENEFITS
44	Plan	Rx 7-25	Rx 7-25	Rx 9-35	Rx HSA	Rx 9-35 PC
45	Pharmacy Benefit Manager	Navitus	Navitus	Navitus	Navitus	Navitus
46	Individual/Family Brand & Specialty Rx Deductibles	none	none	none	Included w/ Medical ded	none
47	Individual/Family Rx Out-of-Pocket (OOP) Max (includes Rx deductibles and co-pays)	$1,500/$2,500	$1,500/$2,500	$2,500/$3,500	Included w/ Med OOP Max	$2,500/$3,500
48	Generic co-pay/30 days supply	$0 at Costco‡ $7 at Other Network	$0 at Costco‡ $7 at Other Network	$0 at Costco‡ $9 at Other Network	Deductible, then $0 at Costco or $9 at Other Network	$0 at Costco‡ $9 at Other Network
49	Brand co-pay/30 days supply	$25	$25	$35	Deductible, then $35	$35
50	Specialty co-pay/up to 30 days supply	$25 Must Use Navitus Mail	$25 Must Use Navitus Mail	$35 Must Use Navitus Mail	Deductible, then $35 (Must Use Navitus Mail)	$35 Must Use Navitus Mail
51	Mail Order (Generic-Brand co-pay/90 days supply)	$0-$60‡	$0-$60‡	$0-$90‡	Deductible, then $0-$90	$0-$90‡
52	Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy	Costco Mail Order Pharmacy
53	This comparison displays member cost-share for In-Network services. Out-of-Network services may not be covered. Please refer to the plan documents available through your district for applicable details, limitations, and exclusions. Employee cost/payroll deduction, if applicable, can be requested from the district.
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