Important Documents

Booklet

Claim Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foundation Plan

Overview

San Jose Unified School District Foundation Plan
	Level One Blue Cross Providers	Level Two Out of Network
Individual Deductible	$100	$200
Family Deductible	$300	$600
Annual Out-of-Pocket Maximum	After deductible, plan pays 80% for first $5,000 of covered expenses and 100% thereafter for each calendar year.	After deductible, plan pays 60%* of covered expenses for each calendar year
Lifetime Maximum	$1,500,000 per member	$1,500,000 per member
Benefits for Covered Services
Physician Services:
Office Visits	$15	60%*
Hospital/Skilled Nursing Visits	80%	60%*
Specialist Office Visits	$15	60%*
Surgeon/Asst. Surgeon	80%	60%*
Anesthesiologist	80%	60%*
Diagnostic X-ray & Labs	80%	60%*
Mental and Nervous Care (excludes severe mental disorders):
Inpatient	80%, up to a maximum of 30 days per year	60%*, up to a maximum of 30 days per year
Outpatient	Visits 1-3 paid at 100% of allowance Visits 4-50 paid at 80% of allowance Maximum of 50 outpatient visits per year	Visits 1-3 paid at 100% of allowance Visits 4-50 paid at 60% of allowance Maximum of 50 outpatient visits per year
Hospital/Surgical Services:
Inpatient	80%	60%*
Outpatient	80%	60%*
Emergency Services:
Ambulance	80%	60%*
Emergency Room	80% after $50 copay, waived if life-threatening or admitted	60%* after $50 copay, waived if life-threatening or admitted
Maternity Services:
Hospital Benefits - Delivery	80%	60%*
Outpatient Physician Services	$15	60%*
Surgical Services	80%	60%*
Prescription Drugs:
Generic or Brand	80%	80%
Mail Order:
Generic	$5 copay, 90 day supply	$5 copay, 90 day supply
Brand	$15 copay, 90 day supply	$15 copay, 90 day supply
Caremark - Foundation 300 Plan
Other Services:
Chiropractic Services	$15	60%*
Continued Care Services	80%
Skilled Nursing Facility	Following discharge from an acute care facility, plan pays 80%	Following discharge from an acute care facility, plan pays 60%*
Physical Therapy	80%	60%*
Speech Therapy	80%	60%*
*If a Blue Cross Prudent Buyer Network provider is not available in the area where treatment is received, the plan will pay 80%* of the covered expense amount.