how to choose the health plan that s right for you

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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.


Q: How can I figure out which health plan is right for me? A: First, consider how much coverage you need. Are you

single, or do you have a family? Do you or a family member have a chronic condition? It’s important to look at the full range of services and copayments (or “copays”) you will spend out of pocket for doctors’ visits, surgery, hospital stays, or other types of care. And it’s important to know whether your plan covers preventive services, prescription drugs, new glasses, or other services you may need.

Q: Does this health plan’s network include the doctors and hospitals I want?

A: If you already have a family doctor, you may want to check to see if your doctor is included in the health plan’s network.

Q: What about cost? Should it be a factor in the decision? A: The cost of coverage is an important issue. You need to


Q: What are my options?

A: You can choose an HMO or PPO health plan. There are many differences between these two types of plans, but the most significant is how you access covered services and how much you will pay out-of-pocket for these services, including any applicable deductibles. With an HMO, you must live or work within the service area covered by the plan. You also need to access all care from a medical group in the HMO provider network and designate a primary care physician or Personal Physician to coordinate all your healthcare needs. Check to see if your health plan offers a direct referral option to specialists within your medical group for a slightly higher copay.


Q: What if you have a lot of options and are confused about how to narrow down your choices?

A: Start with the basics. You need to know what types of doctors’ visits, surgery, or hospital services are covered in the benefit plan. Find out if the plan covers prescription drugs. And, of course, you need to know how much you’re going to pay out of pocket, if there is a copayment or deductible you need to meet, or if there’s an overall limit or cap on benefits. The bottom line is that it’s important to know how the plan works. Don’t wait until you need health care to ask those important questions.


Consider these other questions when comparing plan options.

Does the health plan help keep you well? 1. Cover preventive care to help you stay well? 2. Offer member programs and wellness discounts? 3. Offer incentives to stay well and adopt healthy habits? 4. Provide wellness programs to encourage a healthy


5. Offer access to resources related to women’s health, men’s health, and the health of children and seniors? Does the health plan make it easy for you to find quality care?

1. Have tools and resources to find local providers online? 2. Offer a hospital comparison tool to help you evaluate

hospitals that are available to you?

Does the health plan help you manage your prescriptions? 1. Allow you to e-mail a pharmacist for drug information? 2. Offer a mail order benefit that not only saves

you money but is convenient?



Does the health plan keep your family covered? 1. Offer coverage to families living apart and

dependent college students living outside California? 2. Are your children’s pediatricians or specialists in

the network?

Does the health plan offer additional value-added services

1. Provide tools and resources to help you save money? 2. Provide you access to life management resources? 3. Offer discounts to services you use regularly? Does the health plan make it easy to do business with them?

1. Let you change doctors, order new ID cards, and view your claims history online?

2. Have dedicated calling centers to help you with claims and questions?


to consider ...


Health plan

cost comparison

Compare benefits

Plan A

How much

is covered? You pay


Health plan

cost comparison

Plan B Plan C

How much

is covered? You pay How much is covered? You pay

Annual physical/ preventive care Office visits Diagnostics (such as lab work) Maternity coverage Well-baby exams Emergency room visits Hospital care (outpatient services) Prescription drug costs Copayment for alternative care visits (such as chiropractic) Mental health services Annual deductible Annual out-of-pocket maximum or copayment maximum Lifetime maximum Monthly rate Total costs



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


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 a true medical emergency.

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.


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.

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 higher co-insurance (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 co-insurance 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.


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.

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 ages 18 and over.

Services: Includes medically necessary healthcare

services and medically necessary supplies furnished incident to those services.


Blu e S h ie ld o f C a lif o rn ia is a n In d e p e n d e n t M e m b e r o f t h e B lu e S h ie ld A ss o c ia tio n A 378 09 ( 7/ 09 )

Use this guide to help you make the smart choice for your coverage.

If you need more information about choosing the Blue Shield health plan that’s right for you, our 24/7 Shield Helps hotline is available to you during open enrollment to answer your specific questions, at (888) 678-SHIELD. Or you can visit us online at

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