Active Start Active Start Plan 25 Active Start Plan 25 Generic Rx Active Start Plan 35 Individual Plans Active Start Plan 35 Generic Rx Get value right away, with no deductible to pay. Active StartSM PPO plans* offer a blend of lower costs and comprehensive benefits for active individuals who want coverage in case of a serious medical event, but also want to take care of more routine day-to-day healthcare needs. Active Start plans have no medical deductibles, so your benefits start right away. With fixed, low copayments for physician office visits, going to the doctor won’t cost you a fortune. And with the choice of generic-only, or generic and brand-name prescription drug coverage, you have greater control over your monthly premiums. Four great reasons to choose an Active Start plan today: • Services are available right away – there’s no medical deductible to meet L • ow copayments for office visits and prescription drugs • 100% coverage for most in-network services after meeting the out-of-pocket maximum • Chiropractic and acupuncture benefits Compare for yourself all the great benefits of Active Start plans Active Start 25, Active Start 35, Active Start 25 Generic Rx Active Start 35 Generic Rx Office visits $25 $35 Preventive care exam $0 Mammogram and $0 GYN screening Inpatient hospitalization $500/admit + 40% Outpatient surgery $500/admit + 40% Lab and X-ray 40% Emergency room $100 (waived if admitted) + 40% Maternity Not covered Generic Rx $10 Brand formulary Rx 1 $35 $35 after $500 Brand Rx deductible after $750 Brand Rx deductible -OR- -OR- Not covered on Generic Rx plan2 Not covered on Generic Rx plan2 Annual deductible None None Annual out-of-pocket $6,000 $7,500 maximum per member per member Amounts shown represent the member’s financial responsibility when using Blue Shield network providers, unless otherwise indicated. This document is a summary only. For a detailed description of plan benefits and exclusions, request a copy of the Policy by calling Member Services at (800) 431-2809. click here to apply onine blueshieldca.com Advantages of Blue Shield Individual and Family plans Understanding your plan A • ffordable – we’ve negotiated with providers for To make health coverage easier for you, here is a simple lower fees, so you’ll pay less for covered medical description of how these plans work: services. A lot less. W • ith no deductible, you’ll receive most benefits – like W • ith more than 60,000 doctors, Blue Shield has some office visits and generic prescription drugs – right of the largest PPO provider networks in California. If away for a copayment. you already have a doctor, chances are your doctor Y • ou’ll pay the reduced fee we negotiated with your is in one of our networks. provider until you’ve reached your annual out-of- L • ots of extras such as around-the-clock access to a pocket maximum. After that, we’ll pay 100% for most registered nurse, wellness programs and discounts, covered medical services.1 and out-of-state coverage at no additional cost. 2 • 0% vision discounts for eye exams, frames and lenses, and other products.3 Take an active approach to your health care. Apply for an An Independent Licensee of the Blue Shield Association A36809 (1/11) Active Start plan today! U * nderwritten by Blue Shield of California Life & Health Insurance Company. Active Start Plan 25 Generic Rx and Active Start Plan 35 Generic Rx are subject to regulatory approval. A 1 mounts you pay for prescriptions do not count toward the out-of-pocket maximum. After you meet the out-of-pocket maximum, copayments for prescriptions will continue. B 2 rand-name prescription drug coverage is not offered under Active Start Plan 25 Generic Rx or Active Start Plan 35 Generic Rx, with the exception of covered drugs and supplies for diabetes. Brand and generic diabetes medications/supplies are covered, and may be subject to Prior Authorization for medical necessity. T 3 he network of practitioners and facilities in the Discount Vision Program are managed by a contracted vision plan administrator (including any screening and credentialing of provider). Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield health plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use the Blue Shield grievance process described in the Grievance Process section of the Policy. Blue Shield reserves the right to terminate this program at any time without notice.