Medical Plans & Pharmacy
HMO Medical Plans
The Meissner Mfg. Co., Inc. health plans are built on choice, offering you the opportunity to make decisions about what will best meet you and your family’s health and financial needs.
With the Health Maintenance Organization (HMO) plan, you must choose a Primary Care Physician (PCP) or medical group/Independent Practice Association within the Blue Shield Network. To receive specialty care, you must obtain a referral from your PCP or medical group to a Specialist within the network. And, except in the case of an emergency, you’re only covered for care you receive from providers, facilities and pharmacies that are in the Blue Shield Network. Employee contributes $65 for employee-only cost towards the base plan (Gold Trio HMO 1000/35 OffEx) a month & Meissner pays the employee cost balance.
- Platinum HMO 0/30 OffEx: (full network / narrow network)
- Platinum 0/30 TRIO HMO (narrow network)
- Gold Access+ HMO 500/35 OffEx (full network)
- Gold TRIO HMO 1000/35 OffEx – BASE PLAN (narrow network)
HMO 0/30 OffEx Plan Document | Blue Shield
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HMO 500/35 OffEx Plan Document | Blue Shield
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HMO 1000/35 OffEx Plan Document | Blue Shield
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Blue Shield of California | Platinum Access+ HMO 0/30 OffEx | Blue Shield of California | Gold Access+ HMO 500/35 OffEx | Blue Shield of California | Gold Trio HMO 1000/35 OffEx |
|
|---|---|---|---|
| DEDUCTIBLE (IN-NETWORK) | |||
| Single | $0 | $500 | $1,000 |
| Family | $0 | $1,000 | $2,000 |
| COINSURANCE | |||
| Member % | 0% | 20% | 20% |
| OUT OF POCKET MAXIMUM | |||
| Single | $2,700 | $7,500 | $7,500 |
| Family | $5,400 | $15,000 | $15,000 |
| COMMONLY USED SERVICES | |||
| Primary Care Physician Office Visit | $30 copay | $35 copay | $35 copay |
| Specialist Office Visit | $55 copay | $60 copay | $70 copay |
| Urgent Care | $30 copay | $35 copay | $35 copay |
| Emergency Room | $250 copay | $300 copay | $300 copay |
| PREVENTIVE CARE | |||
| Preventative Services | No charge | No charge | No charge |
| MAJOR MEDICAL EXPENSES | |||
| Outpatient Surgery | Ambulatory: $100 / Hospital: $150 | Ambulatory: $150 / Hospital: $300 | Ambulatory: $150 / Hospital: $300 |
| Inpatient Hospitalization / Surgery | $500 per day up to 4 days per admission | 20% after deductible | 20% after deductible |
| CT scan, PET scan, MRI | Radiology: $100 / Hospital: $250 | Radiology: $100 / Hospital: $250 | Radiology: $100 / Hospital: $300 |
| Hospital Newborn Delivery | $500 per day up to 4 days per admission | 20% after deductible | 20% after deductible |
| PRESCRIPTION DRUG COVERAGE | |||
| Prescription Deductible | None | None | $0 |
| Generic (Tier 1) | $5 copay | $15 copay | Level A: $15 / Level B: $20 |
| Brand Name (Tier 2) | $25 copay | $50 copay | Level A: $40 / Level B: $60 |
| Non-Preferred (Tier 3) | $30 copay | $70 copay | Level A: $60 / Level B: $90 |
| Specialty (Tier 4) | 20% up to $250 | 20% up to $250 | 20% up to $250 |
| Mail Order - 90 day Supply | $10 / $50 / $60 / 20% up to $500 | $30 / $100 / $140 / 20% up to $500 | $30 / $80 / $120 / 20% up to $500 |
The Full PPO Network, Blue Shield’s largest in California and offers lower out-of-pocket costs when using in-network providers, allows access to out-of-network care at higher rates, requires no specialist referrals, includes nationwide coverage through the BlueCard® program, and provides flexibility in choosing providers with added savings when staying in-network.
PPO Medical Plan
Gold Full PPO 0/35 OffEx Plan Document | Blue Shield
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Gold Full PPO 0/35 OffEx |
||
|---|---|---|
| DEDUCTIBLE | IN-NETWORK | OUT-OF-NETWORK |
| Single | $0 | $1,000 |
| Family | $0 | $2,000 |
| Member % after deductible | None | 40% |
| OUT OF POCKET MAXIMUM | ||
| Single | $7,900 | $15,800 |
| Family | $15,800 | $31,600 |
| COMMONLY USED SERVICES | ||
| Primary Care Physician Office Visit | $35 copay | 40% after deductible |
| Specialist Office Visit | $60 copay | 40% after deductible |
| Urgent Care | $35 copay | 40% after deductible |
| Emergency Room (waived if admitted) | $250/visit plus 30% | $250/visit plus 30% |
| PREVENTATIVE CARE | ||
| Preventive Services | No Charge | Not covered |
| MAJOR MEDICAL EXPENSES | ||
| Outpatient Surgery | Ambulatory: 30% / Hospital: $150 + 30% after deductible | 40% after deductible |
| Inpatient Hospitalization / Surgery | 30% after deductible | 40% after deductible |
| CT scan, PET scan, MRI | Hospital: 30% / Radiology: $100 + 30% after deductible | 40% after deductible |
| Hospital Newborn Delivery | 30% after deductible | 40% after deductible |
| Generic (Tier 1) | $25 copay | Not covered |
| Brand Name (Tier 2) | $50 copay | Not covered |
| Non-Preferred (Tier 3) | $70 copay | Not covered |
| Specialty (Tier 4) | 30% up to $250 | Not covered |
| Mail Order - 90 day Supply | $50 / $100 / $140 / 30% up to $500 | Not covered |
Medical Rates
| Gold 500/35 - Access+ HMO | Platinum 0/30 - Access+ HMO | Gold 1000/35 - Trio HMO | Platinum 0/30 - Trio HMO | Gold 0/35 - Full PPO | |||||
|---|---|---|---|---|---|---|---|---|---|
| Age | Rates | Age | Rates | Age | Rates | Age | Rates | Age | Rates |
| 0-14 | $383.26 | 0-14 | $412.36 | 0-14 | $324.64 | 0-14 | $356.75 | 0-14 | $459.11 |
| 15 | $417.33 | 15 | $449.02 | 15 | $353.49 | 15 | $388.46 | 15 | $499.92 |
| 16 | $430.36 | 16 | $463.03 | 16 | $364.53 | 16 | $400.59 | 16 | $515.53 |
| 17 | $443.38 | 17 | $477.05 | 17 | $375.56 | 17 | $412.71 | 17 | $531.13 |
| 18 | $457.41 | 18 | $492.14 | 18 | $387.44 | 18 | $425.77 | 18 | $547.94 |
| 19 | $471.44 | 19 | $507.24 | 19 | $399.33 | 19 | $438.83 | 19 | $564.74 |
| 20 | $485.97 | 20 | $522.87 | 20 | $411.63 | 20 | $452.35 | 20 | $582.15 |
| 21 | $501.00 | 21 | $539.04 | 21 | $424.36 | 21 | $466.34 | 21 | $600.15 |
| 22 | $501.00 | 22 | $539.04 | 22 | $424.36 | 22 | $466.34 | 22 | $600.15 |
| 23 | $501.00 | 23 | $539.04 | 23 | $424.36 | 23 | $466.34 | 23 | $600.15 |
| 24 | $501.00 | 24 | $539.04 | 24 | $424.36 | 24 | $466.34 | 24 | $600.15 |
| 25 | $503.00 | 25 | $541.19 | 25 | $426.06 | 25 | $468.21 | 25 | $602.55 |
| 26 | $513.02 | 26 | $551.98 | 26 | $434.55 | 26 | $477.53 | 26 | $614.55 |
| 27 | $525.05 | 27 | $564.91 | 27 | $444.73 | 27 | $488.73 | 27 | $628.96 |
| 28 | $544.58 | 28 | $585.93 | 28 | $461.28 | 28 | $506.91 | 28 | $652.36 |
| 29 | $560.62 | 29 | $603.18 | 29 | $474.86 | 29 | $521.84 | 29 | $671.57 |
| 30 | $568.63 | 30 | $611.81 | 30 | $481.65 | 30 | $529.30 | 30 | $681.17 |
| 31 | $580.66 | 31 | $624.75 | 31 | $491.84 | 31 | $540.49 | 31 | $695.57 |
| 32 | $592.68 | 32 | $637.68 | 32 | $502.02 | 32 | $551.68 | 32 | $709.98 |
| 33 | $600.20 | 33 | $645.77 | 33 | $508.39 | 33 | $558.68 | 33 | $718.98 |
| 34 | $608.21 | 34 | $654.39 | 34 | $515.18 | 34 | $566.14 | 34 | $728.58 |
| 35 | $612.22 | 35 | $658.70 | 35 | $518.57 | 35 | $569.87 | 35 | $733.38 |
| 36 | $616.23 | 36 | $663.02 | 36 | $521.97 | 36 | $573.60 | 36 | $738.18 |
| 37 | $620.24 | 37 | $667.33 | 37 | $525.36 | 37 | $577.33 | 37 | $742.99 |
| 38 | $624.24 | 38 | $671.64 | 38 | $528.76 | 38 | $581.06 | 38 | $747.79 |
| 39 | $632.26 | 39 | $680.27 | 39 | $535.55 | 39 | $588.52 | 39 | $757.39 |
| 40 | $640.28 | 40 | $688.89 | 40 | $542.34 | 40 | $595.99 | 40 | $766.99 |
| 41 | $652.30 | 41 | $701.83 | 41 | $552.52 | 41 | $607.18 | 41 | $781.39 |
| 42 | $663.82 | 42 | $714.23 | 42 | $562.28 | 42 | $617.90 | 42 | $795.20 |
| 43 | $679.85 | 43 | $731.48 | 43 | $575.86 | 43 | $632.83 | 43 | $814.40 |
| 44 | $699.89 | 44 | $753.04 | 44 | $592.84 | 44 | $651.48 | 44 | $838.41 |
| 45 | $723.44 | 45 | $778.37 | 45 | $612.78 | 45 | $673.40 | 45 | $866.62 |
| 46 | $751.50 | 46 | $808.56 | 46 | $636.55 | 46 | $699.51 | 46 | $900.22 |
| 47 | $783.06 | 47 | $842.52 | 47 | $663.28 | 47 | $728.89 | 47 | $938.03 |
| 48 | $819.13 | 48 | $881.33 | 48 | $693.83 | 48 | $762.47 | 48 | $981.24 |
| 49 | $854.70 | 49 | $919.60 | 49 | $723.96 | 49 | $795.58 | 49 | $1,023.86 |
| 50 | $894.78 | 50 | $962.72 | 50 | $757.91 | 50 | $832.89 | 50 | $1,071.87 |
| 51 | $934.36 | 51 | $1,005.31 | 51 | $791.44 | 51 | $869.73 | 51 | $1,119.28 |
| 52 | $977.95 | 52 | $1,052.20 | 52 | $828.36 | 52 | $910.30 | 52 | $1,171.49 |
| 53 | $1,022.04 | 53 | $1,099.64 | 53 | $865.70 | 53 | $951.34 | 53 | $1,224.31 |
| 54 | $1,069.63 | 54 | $1,150.85 | 54 | $906.02 | 54 | $995.64 | 54 | $1,281.32 |
| 55 | $1,117.23 | 55 | $1,202.06 | 55 | $946.33 | 55 | $1,039.94 | 55 | $1,338.33 |
| 56 | $1,168.83 | 56 | $1,257.58 | 56 | $990.04 | 56 | $1,087.98 | 56 | $1,400.15 |
| 57 | $1,220.93 | 57 | $1,313.64 | 57 | $1,034.17 | 57 | $1,136.48 | 57 | $1,462.56 |
| 58 | $1,276.54 | 58 | $1,373.47 | 58 | $1,081.28 | 58 | $1,188.24 | 58 | $1,529.18 |
| 59 | $1,304.10 | 59 | $1,403.12 | 59 | $1,104.62 | 59 | $1,213.89 | 59 | $1,562.19 |
| 60 | $1,359.71 | 60 | $1,462.95 | 60 | $1,151.72 | 60 | $1,265.65 | 60 | $1,628.81 |
| 61 | $1,407.80 | 61 | $1,514.70 | 61 | $1,192.46 | 61 | $1,310.42 | 61 | $1,686.42 |
| 62 | $1,439.37 | 62 | $1,548.66 | 62 | $1,219.20 | 62 | $1,339.80 | 62 | $1,724.23 |
| 63 | $1,478.95 | 63 | $1,591.24 | 63 | $1,252.72 | 63 | $1,376.64 | 63 | $1,771.64 |
| 64-99 | $1,502.99 | 64-99 | $1,617.11 | 64-99 | $1,273.08 | 64-99 | $1,399.02 | 64-99 | $1,800.45 |
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